Citation Nr: 1817907 Decision Date: 03/22/18 Archive Date: 04/03/18 DOCKET NO. 14-24 813 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for erectile dysfunction as secondary to service-connected coronary artery disease. ATTORNEY FOR THE BOARD T. G., Associate Counsel INTRODUCTION The Veteran had active duty service in the U.S. Marine Corps from August 1963 to August 1970 and in the U.S. Army from January 1971 to January 1974. This case is before the Board of Veteran's Appeals (Board) on appeal from a November 2013 rating decision of the Atlanta, Georgia Department of Veterans Affairs (VA) Regional Office (RO). In March 2016, the Board remanded the claim for additional development. Pursuant to the Board's remand, the agency of original jurisdiction (AOJ) scheduled the Veteran for appropriate VA examinations, searched for outstanding VA treatment records, provided the appropriate notice to the Veteran, and issued a supplemental statement of the case. Based on the foregoing actions, the Board finds that there has been substantial compliance with the Board's remand. Stegall v. West, 11 Vet. App. 268 (1998) (finding that a remand by the Board confers on the appellant the right to compliance with the remand orders). FINDING OF FACT The Veteran's erectile dysfunction has not been linked to service or to a service-connected disability. CONCLUSION OF LAW Service connection for erectile dysfunction, to include as secondary to service-connected coronary artery disease is not warranted. 38 U.S.C. §§ 1110, 1113, 1116, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist VA provided the Veteran with 38 U.S.C. § 5103(a)-compliant notice most recently in March 2016. The record also shows that VA has fulfilled its obligation to assist the Veteran in developing the claims, including with respect to VA examination of the Veteran. Neither the Veteran nor his representative has identified any deficiency in VA's notice or assistance duties. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). II. Law and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310 (a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). III. Factual Background The Veteran's service treatment records are silent for any compliant of, treatment for, or diagnosis of erectile dysfunction. On a July 2009 SCPA Office Visit note, Dr. T. G. reported that the Veteran indicated that he was having an intermittent problem with erectile dysfunction and that he was going through counseling with his wife and a psychologist. In a January 2013 Statement in Support of Claim, the Veteran reported that he was placed on a medication called Procardia after his myocardial infraction in April 1998. The Veteran noted that erectile dysfunction is a known side effect of Procardia medication. The Veteran indicated that after he was released from the hospital and permitted to engage in sexual activity, he had an extremely difficulty time achieving an erection. The Veteran reported that this had never occurred prior to his heart attack. The Veteran noted that he was prescribed Viagra in order to engage in sexual activity and that the medication worked for a while. On a November 2013 VA examination, the examiner reported that the Veteran was diagnosed with erectile dysfunction in 1998. The Veteran indicated that he was placed on a medication called Procardia after his myocardial infraction in April 1998. The Veteran noted that erectile dysfunction is a known side effect of Procardia medication. The Veteran indicated that after he was released from the hospital and permitted to engage in sexual activity, he had an extremely difficulty time achieving an erection. The Veteran reported that this had never occurred prior to his heart attack. The Veteran noted that he was prescribed Viagra in order to engage in sexual activity and that the medication worked for a while. The examiner opined that the Veteran's erectile dysfunction was less likely than not proximately due to or the result of the Veteran's service-connected coronary artery disease. The examiner noted in her rationale that his erectile dysfunction was not due to his coronary artery disease, and she could not determine the exact etiology of his erectile dysfunction because he had other risk factors such as hyperlipidemia, hypertension, hypercholesterolemia, and medications. In a July 2014 statement, the Veteran noted his heart medication included Pravachol and Procardia since 1998, and one of Procardia's known side effects is erectile dysfunction. In a March 2016 VA medical opinion, the examiner determined that the Veteran's erectile dysfunction was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale offered was that the Veteran's service records did not document a chronic on-going treatment or condition for erectile dysfunction. The examiner determined that the Veteran's post-service medical records did not document that his current erectile dysfunction was secondary to coronary artery disease or medications for coronary artery disease including Pravachol and Procardia. The examiner concluded that the Procardia medication was not the cause of the Veteran's erectile dysfunction, as he had problems with erectile dysfunction both on and off Procardia. The rationale states that the Veteran's medical records document that he has multiple other probable causes for his erectile dysfunction, including age, hyperlipidemia, anxiety, and anti-anxiety medication. Additionally, the examiner determined that the Veteran's erectile dysfunction was not aggravated beyond its normal progression by his coronary artery disease and coronary artery disease medications, including Pravachol and Procardia. The examiner concluded that the Veteran had problems with erectile dysfunction both on and off Procardia so Procardia was not the cause of his erectile dysfunction and that the Veteran's medical records document that he has multiple other probable causes for his erectile dysfunction, including age, hyperlipidemia, anxiety, and anti-anxiety medication. In April 2016, the Veteran submitted two online articles and several abstract website addresses. The first article was entitled, "Linking erectile dysfunction and coronary artery disease" written by J. J. Rodriquez, R. A. Dashti, and E. R. Schwarz. The second entitled, "Erectile dysfunction: A sign of heart disease?" written by an unnamed Mayo Clinic Staff clinician. IV. Analysis The Veteran asserts that his erectile dysfunction is secondary to his service-connected coronary artery disease or by medications being used to treat the coronary artery disease including Pravachol and Procardia. The Veteran contends that erectile dysfunction had its onset in 1998, many years after service separation, and the evidence of record does not otherwise indicate that the erectile dysfunction was causally or etiologically related to service, nor does the Veteran contend otherwise; therefore, the Board will not address whether service connection is warranted for erectile dysfunction under a theory of direct service connection. Cf. Robinson v. Mansfield, 21 Vet. App. 545, 553 (2008) (VA must consider the possible theories of entitlement raised by the claimant or the evidence of record). Initially, the Board finds that the Veteran currently has erectile dysfunction. During the November 2013 VA examination, the Veteran reported a history of erectile dysfunction with onset in 1998. The Veteran is competent to report erectile dysfunction. Next, the Veteran is service connected for coronary artery disease. After a review of all the evidence, lay and medical, the Board finds that the weight of the evidence is against a finding that the current erectile dysfunction disorder was caused or permanently worsened by coronary artery disease or medication being used to treat the service-connected coronary artery disease. The March 2016 VA addendum opinion indicated that the Veteran's service records did not document a chronic on-going treatment or condition for erectile dysfunction. Moreover, the March 2016 VA addendum opinion noted that the Veteran's current erectile dysfunction was not secondary to coronary artery disease or medications for coronary artery disease including Pravachol and Procardia. The examiner concluded that the Procardia medication was not the cause of the Veteran's erectile dysfunction, as he had problems with erectile dysfunction both on and off Procardia. Additionally, the examiner indicated that the Veteran's medical records document that he has multiple other probable causes for his erectile dysfunction, including age, hyperlipidemia, anxiety, and anti-anxiety medication. Regarding whether the Veteran's erectile dysfunction was aggravated beyond its normal progression by his coronary artery disease and coronary artery disease medications, including Pravachol and Procardia, the examiner determined that the Veteran's erectile dysfunction was not aggravated beyond its normal progression. The examiner reasoned that the Veteran had problems with erectile dysfunction both on and off Procardia so Procardia was not the cause of his erectile dysfunction and that the Veteran's medical records document that he has multiple other probable causes for his erectile dysfunction, including age, hyperlipidemia, anxiety, and anti-anxiety medication. The Board finds the March 2016 VA examination report probative evidence that the Veteran's erectile dysfunction was not caused or permanently worsened (aggravated) by the Veteran's service-connected coronary artery disease or the medications taken to treat the service-connected coronary artery disease. The VA examiner had the requisite medical expertise to render a medical opinion regarding the etiology of the disorder and had sufficient and accurate facts, factual assumptions, and data on which to base the conclusions. The Veteran submitted abstracts from two scientific studies "Linking Erectile Dysfunction and Coronary Artery Disease" and "Erectile Dysfunction: A sign of heart disease?" The U.S. Court of Appeals for Veterans Claims (Court) has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998) and Wallin v. West, 11 Vet. App. 509 (1998). The Board finds that the article abstracts submitted by the Veteran suggest a mere possibility, but not probability, of a relationship between erectile dysfunction and coronary artery disease in general in some patients and also do not relate such a possibility to this specific Veteran. See 38 C.F.R. § 3.102 (decisions of service connection are not to be based on pure speculation or remote possibility); Obert v. Brown, 5 Vet. App. 30 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (holding that a letter from a physician indicating that the veteran's death "may or may not" have been averted if medical personnel could have effectively intubated the veteran was held to be speculative); Warren v. Brown, 6 Vet. App. 4, 6 (1993) (stating that a physician's statement framed in terms such as "may" or "could" is not probative); Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992) (holding that evidence favorable to the veteran's claim that does little more than suggest a possibility that his illnesses might have been caused by service radiation exposure is insufficient to establish service connection). As such, the Board accords the article abstracts low probative weight, and finds them to be outweighed by more specific medical opinion evidence pertaining to this Veteran. To the extent that the Veteran has asserted that erectile dysfunction is due to his service connected coronary artery disease or the medication for service-connected coronary artery disease, in this case, the evidence has not demonstrated that the Veteran possesses the knowledge, training, or experience to provide a competent medical opinion regarding the etiology of the current erectile dysfunction. See Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011) (recognizing ACL injury is a medically complex disorder that required a medical opinion to diagnose and to relate to service). In this case, a competent medical opinion would require comprehensive knowledge of male sexual arousal, which is a complex process that involves the brain, hormones, emotions, nerves, muscles and blood vessels. The etiology of erectile dysfunction, which can also be caused or worsened by stress, mental health problems, or other health impairments, is complex, and not capable of lay observation. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis); see also Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (stating that it "is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"). As the evidence does not show the Veteran to have such knowledge, understanding, or ability, the Veteran's statements regarding the etiology of the erectile dysfunction disorder are not afforded any probative weight. In sum, the competent evidence, including the March 2016 VA medical opinion, weighs against a finding that the current erectile dysfunction was caused or permanently worsened by the service connected coronary artery disease or the medication used for treatment of service-connected coronary artery disease. As such, the Board finds that the preponderance of the evidence is against the theory of secondary service connection for erectile dysfunction, the claim must be denied under this theory, and the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board does not reach the theory of direct service connection because the Veteran has not asserted that the erectile dysfunction disorder was incurred in service, and has consistently contended only that the erectile dysfunction disorder diagnosed after service is due to his service connected coronary artery disease or the medication for the service-connected coronary artery disease. ORDER Entitlement to service connection for erectile dysfunction as secondary to service-connected coronary artery disease is denied. ____________________________________________ KELLI A. KORDICH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs