Citation Nr: 1823331 Decision Date: 04/17/18 Archive Date: 04/25/18 DOCKET NO. 12-09 276 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for erectile dysfunction (ED), claimed as secondary to service-connected disabilities of diabetes mellitus and other specified trauma and stressor related disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Morrad, Associate Counsel INTRODUCTION The Veteran had active service from August 1965 to April 1969. This matter comes before the Board of Veterans' Affairs (Board) on appeal from a March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In June 2011, the Veteran filed a Notice of Disagreement. The RO furnished the Veteran a Statement of the Case in March 2012. The Veteran filed a Substantive Appeal (VA Form 9) in April 2012 and a videoconference hearing before the undersigned was held in May 2014. This matter was before the Board in October 2014 and June 2017and was remanded for further development. In a November 2017 rating decision, the RO granted service connection for high blood pressure. This represents a full grant of benefits sought and the remaining issue on appeal has been recharacterized accordingly. This claim has been processed through the Veterans Benefits Management System (VBMS) and the Virtual VA (Legacy) claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of these electronic documents. FINDINGS OF FACT 1. The Veteran's ED is not proximately due to or aggravated by his service-connected diabetes mellitus. 2. The Veteran's ED is not proximately due to or aggravated by his service-connected other specified trauma and stressor related disorder. CONCLUSION OF LAW The criteria for establishing service connection for ED have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2017). Specifically, the Board finds that VA has satisfied its duty to notify under the Veterans Claims Assistance Act (VCAA) by way of a letter sent in June 2009, prior to the initial unfavorable decision by the RO. Such letter advised the Veteran of the evidence and information necessary to substantiate his claim. Furthermore, the Veteran was informed of his and VA's respective responsibilities in obtaining such evidence and information. VA has obtained service treatment records and afforded the Veteran the opportunity to give testimony before the Board. All known and available records relevant to the issue decided below have been obtained and associated with the Veteran's electronic claims file. The Veteran has been provided with a VA examination and accompanying addendum opinions that address the contended causal relationship between the claimed disability and his service-connected diabetes mellitus and his service-connected other specified trauma and stressor related disorder. 38 U.S.C. §5103A; 38 C.F.R. §3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Given that the pertinent medical history was noted by the examiners, the examination reports set forth detailed examination findings in a manner that allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examination and accompanying report of record are adequate for rating purposes and additional examination is not necessary regarding the claim. See also 38 C.F.R. §§3.326, 3.327, 4.2. Additionally, the Board finds that there has been substantial compliance with its June 2017 remand directives. The Board thus finds that all necessary development has been accomplished and appellate review may proceed. See Bernard v. Brown, 4 Vet. App. 384 (1993). Rules and Regulations Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). In order to prevail on the issue of service connection, there must competent, credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus, or link, between the current disability and the in-service disease or injury and the present disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for: (1) a disability that is proximately due to or the result of a service-connected disease or injury; or, (2) any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38 C.F.R. §§3.310(a)-(b); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993) (explaining 38 C.F.R. §3.310(a)); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (explaining 38 C.F.R. §3.310(b)). In order to establish service connection for a disability on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) competent nexus evidence establishing a connection, or link between, the current disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Lay evidence can be competent and sufficient to establish a diagnosis when a layperson (1) is competent to identify the medical condition; or, (2) is reporting a contemporaneous medical diagnosis; or, (3) describes symptoms at the time that supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although a lay person is competent in certain situations to provide a diagnosis of a simple condition, a lay person is not competent to provide evidence as to more complex medical questions. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Likewise, mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). It is VA policy to administer the laws and regulations governing disability claims under a broad interpretation and consistent with the facts shown in every case. When a reasonable doubt arises regarding service origin, the degree of disability, or any other point, after careful consideration of all procurable and assembled data, such doubt will be resolved in favor of the claimant. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not prove or disprove the claim satisfactorily. It is a substantial doubt and one within range of probability as distinguished from pure speculation or remote possibility. See 38 C.F.R. §3.102. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). Factual Background The Veteran claims that he suffers from ED secondary to his service-connected diabetes mellitus. The Veteran also contends that he suffers from ED secondary to his service-connected other specified trauma and stressor related disorder. The Veteran was provided with a VA genitourinary examination in September 2010 to determine the nature and etiology of his ED. The Veteran reported that he began having problems having an erection around 2006. He mentioned this to his primary doctor who gave him samples of medication, which did not help him. The Veteran denied any symptoms attributable to renal dysfunction, specifically lethargy, weakness, anorexia, or weight loss. The Veteran stated that ejaculation is not possible and the last time he had sexual intercourse was about 3 years ago. The examiner noted that the genitourinary examination showed that the Veteran is a well-developed male. Inspection and palpation of the penis, testicles, epididymides and spermatic cord were normal. There was no penis deformity. There was no definite enlargement of the prostate. Sensation and reflexes around the perineal area were normal. There was no testicular atrophy. The examiner diagnosed the Veteran with ED and opined that it is not caused by or related to diabetes. The rationale provided was that the Veteran's testosterone level is less than normal indicating the dysfunction is due to low hormone levels and not due to diabetes. In December 2014, the VA examiner that conducted the September 2010 examination provided an addendum opinion regarding the Veteran's ED. The VA examiner opined that the Veteran's ED was not at least as likely as not aggravated beyond its natural progression by his diabetes. The examiner noted that the Veteran has ED due to low testosterone level. The ED was found not to have been aggravated by diabetes. Testosterone was noted to be 143 in 2010 and it was 182 in 2012. In another addendum opinion provided in June 2017, a VA examiner opined that the Veteran's ED is less likely than not caused by or aggravated by his service-connected diabetes. The rationale provided was that the Veteran was noted to have low testosterone in 2010 and 2012 which is more likely the cause of ED. This is attributed to hypogonadism as seen in the Veteran's problem list in his medical records at Dayton VA. The examiner added that diabetes causes microvascular disease and it does not lower testosterone levels. The examiner also opined that the Veteran's ED is less likely than not caused by or aggravated by his service-connected specified trauma and stressor related disorder. The rationale provided was that the ED is more likely due to objective data of lower testosterone levels which signify hypogonadism as listed in the problem list of the Veteran's medical records. Analysis Upon review of the foregoing evidence, the Board concludes that the Veteran is not entitled to service connection for ED as secondary to his service-connected diabetes mellitus or as secondary to his service-connected other specified trauma and stressor related disorder. As an initial matter, the Board notes that the Veteran has been diagnosed with ED. As such, the Board finds that the current disability element is established. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Thus, the issue turns upon whether there is evidence of the disease being caused by a service-connected disability. If so, evidence of a nexus between the service-connected disability and the present disability is required for the establishment of service connection. The September 2010 VA examination report and December 2014 and June 2017 accompanying addendum opinions reveal negative nexus opinions regarding causation or aggravation of the Veteran's ED by his service-connected diabetes mellitus or his service-connected other specified trauma and stressor related disorder. The Board finds these examination reports to be highly probative because the VA examiners reviewed the Veteran's medical history and provided adequate rationales as to why they thought the Veteran's current ED is not at least as likely as not caused by or aggravated by his service-connected diabetes mellitus or his service-connected other specified trauma and stressor related disorder. The Board acknowledges the article submitted by the Veteran in April 2014 suggesting a link between diabetes and ED in some men. However, the VA examiner that provided the medical opinion in June 2017 reviewed all of the evidence in the Veteran's record and still opined that the Veteran's ED is less likely than not caused by or aggravated by his service-connected diabetes. The examiner specifically noted that diabetes does not itself lower testosterone levels. The medical expert opinions outweigh the speculative lay opinion evidence. The Board also recognizes that the Veteran, through his representative, has alleged that the Veteran's ED as secondary to his service-connected high blood pressure should be considered. However, the VA examination and accompanying addendum opinions all attribute the Veteran's ED to his low testosterone levels. Additionally, the Veteran has not submitted any medical evidence linking his service-connected high blood pressure to his ED. As such, the record does not support the Veteran's contention that his ED is secondary to his service-connected high blood pressure. While the Board is sympathetic to the Veteran's claim, taking into account all of the relevant evidence of record, the preponderance of the evidence is against a finding of an etiological relationship between the Veteran's ED and his service-connected diabetes mellitus or his service connected other specified trauma and stressor related disorder. Accordingly, the Board finds that the claim of entitlement to service connection for ED as secondary to service-connected diabetes mellitus or his service connected other specified trauma and stressor related disorder must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. §5107(b); 38 C.F.R. §3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for ED, claimed as secondary to service-connected disabilities of diabetes mellitus and other specified trauma and stressor related disorder is denied. ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs