Citation Nr: 21002561 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 10-00 155 DATE: January 14, 2021 REMANDED Service connection for residuals of a urinary tract infection (UTI) disability is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1981 to March 1990. This matter originally came before the Board of Veterans’ Appeals (Board) from a July 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. The Veteran testified at a January 2017 Travel Board hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the claims file. This matter has previously been remanded by the Board for further development, most recently in April 2020. This matter is again before the Board and has been advanced on the docket pursuant to 38 C.F.R. § 20.902(c). Service connection for residuals of a UTI disability is remanded. The Veteran believes that service connection for residuals of a UTI disability is warranted. He stated that he originally had a urinary tract infection when he experienced right epididymitis in service. See January 2017 Hearing Transcript. The most recent UTI examination took place in July 2020. Among other things, the examination found that the Veteran had acute UTIs in 2009, 2010, and 2017; and that there was no medical evidence of a recurrent UTI. See July 2020 C&P Exam. Upon review, the Board finds the July 2020 examination inadequate because it did not consider/was unable to consider all the relevant evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Specifically, among other evidence, the examination did not consider/was unable to consider numerous medical records showing hematuria; medical records from 2018 showing medication for a UTI; medical records from 2017 showing a diagnosis of voided urine (cytospins) with rare urothelial cells in the background of abundant obscuring acute inflammation; medical records from 2019 showing a partially distended urinary bladder; medical records from 2019 showing the Veteran’s report of hematuria with burning, urgency, hesitancy, frequency, and weak urine stream; medical records from 2019 showing that the Veteran had UTIs; medical records from 2018 showing that a nurse practitioner stated that the Veteran had UTIs quite often; medical records from 2017 showing that the Veteran had some areas of apparent trauma to the prostatic urethra; medical records showing that certain prescribed medications had the potential side effect of urinary frequency; medical records from 2009 showing that the Veteran was taking medication for bladder spasms; medical records from 2009 stating that the Veteran was told that he had a leaking valve in his penis at one point; and the Veteran’s 2012 report that every now and then, it got hard to urinate and there was discoloration of his urine, so he would get antibiotics for the problem. The VA examination report failed to discuss the significance of any of the evidence discussed above. See November 2020 CAPRI; May 2020 CAPRI; December 2019 CAPRI; April 2019 Medical Treatment Record; October 2018 CAPRI; June 2014 Medical Treatment Record; May 2012 Hearing Testimony. The Board notes that it previously found UTI examinations in February 2019 and December 2019 inadequate. See April 2020 BVA Decision; May 2019 BVA Decision. Therefore, a remand is needed for a new VA examination. The matter is REMANDED for the following action: 1. Update VA and private treatment records. VA treatment records appear current up to November 2020. 2. Schedule an appropriate VA examination for the Veteran’s urinary conditions. The need for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the claims file and a copy of this Remand, the reviewing examiner is requested to furnish an opinion with respect to the following: (A) Identify all urinary related disabilities existing at any point during the pendency of the appeal (i.e. since August 2010), even if they are currently asymptomatic or have resolved during the pendency of the appeal. (B) For each identified disability, is it at least as likely as not (a 50 percent or greater probability) that the disability is related to the Veteran’s service? (C) For each identified disability, is it at least as likely as not (a 50 percent or greater probability) that the disability is/was caused by any or all of the Veteran’s service-connected disabilities (including any medications taken for the service-connected disabilities)? (D) For each identified disability, is it at least as likely as not (a 50 percent or greater probability) that the disability is/was aggravated beyond its natural progression by any or all of the Veteran’s service-connected disabilities (including any medications taken for the service-connected disabilities)? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. (E) Is it at least as likely as not (a 50 percent or greater probability) that any or all of the Veteran’s service-connected disabilities (including any medications taken for the service-connected disabilities) caused or aggravated the Veteran’s obesity/being overweight including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. (F) If yes, is it at least as likely as not (a 50 percent or greater probability) that the obesity/being overweight caused or aggravated any or all of the Veteran’s urinary related disabilities including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. In addition to the other relevant evidence of record, the examiner is asked to consider the following information with a caution that this list is not a substitute for a review of the record: (1) A list of the Veteran’s service-connected disabilities. See April 2020 Rating Decision – Codesheet. (2) Medical records from 2019 and 2020 showing a history of hematuria; body mass indexes of 41.3 and 42.5; and certain prescribed medications, such as hypertension medication, had frequent involuntary urination side effects. See November 2020 CAPRI. (3) Medical records from 2017 showing hematuria in the urine and a diagnosis of voided urine (cytospins), rare urothelial cells in the background of abundant obscuring acute inflammation. Medical records from 2018 showed medication for a UTI. Medical records from 2019 showed a partially distended urinary bladder with fluid. See May 2020 CAPRI. (4) A document listing some of the reasons why previous examinations were inadequate. See April 2020 BVA Decision. (5) Medical records from 2018 showing ongoing hematuria. See February 2020 CAPRI. (6) A medical record from 2019 showing a diagnosis of UTIs from 2017. The Veteran had a history of recurrent symptomatic bladder or urethral infections. He reported getting UTIs about 3 times per year. Septra was ordered for a recurrent UTI in 2017. The Veteran had a voiding dysfunction and the Veteran reported a slow, weak stream. The Veteran also reported getting hematuria when he had UTIs. See December 2019 C&P Exam. (7) Medical records from 2019 showing the Veteran’s report of hematuria with burning, urgency, hesitancy, frequency, and a weak urine stream. See December 2019 CAPRI. (8) Medical records from 2019 showing that the Veteran was suffering from a UTI. See April 2019 Medical Treatment Record. (9) Medical records from 2010 showing that the Veteran had a UTI about once per year and that they were treated with antibiotics. The Veteran was obese. The Veteran had urinary flow problems and reported that he had hesitancy of urine and a decreased force of stream. Medical records from 2017 showed an assessment of microscopic hematuria. The Veteran had some areas of apparent trauma to the prostatic urethra. Antibiotics were prescribed for a recurrent UTI. The Veteran’s bladder was burning, and he had a tingling sensation upon urination. Medical records from 2018 showed that Bactrim was ordered for a UTI. A nurse practitioner stated that the Veteran had UTIs quite often. The Veteran had had hematuria for about 4 months. An adrenal mass was being evaluated. See October 2018 CAPRI. (10) Medical records from 2009 showing that the Veteran was taking medication for a bladder spasm, that the Veteran was taking Ciprofloxacin for an infection, that the Veteran had a rectal dysfunction UTI, and that the Veteran was given medication for erections but only used it twice because it gave him pain and burning. Medications for the UTIs were listed. Id. (11) Medical records from 2017 showing the Veteran’s report that hematuria happened mostly after voiding. There was a diagnosis of SSA. See July 2018 CAPRI. (12) The Veteran’s report that he had been diagnosed with an atrophy of the right testicle with chronic epididymitis to include a UTI. See May 2018 Statement in Support of Claim. (13) The Veteran’s report of recurrent symptomatic UTIs requiring drainage/frequent treatment more than twice per year and requiring continuous intensive management. Functional loss was due to his history of epididymitis. Prescribed UTI medications were listed. See August 2017 Congressional correspondence. (14) The Veteran’s report that during service, he had epididymitis and a UTI. He was prescribed medication for it. It might have been caused by the epididymitis, the atrophied testicle, or something going on in the urinary area. It could have been caused by trauma during service when his testicle twisted, and the blood supply was cut off. He had a UTI related to trauma during service around the year 1982. It was listed as due to a UTI or trauma. The Veteran also reported that a doctor recently told him that his UTI disability was due to the twisted testicle or because of service. See January 2017 Hearing Transcript. (15) Service records showing high blood pressure and that the Veteran lost weight without dieting. See November 2014 STR – Medical. (16) A medical record from 2014 showing that the Veteran had a UTI about once per year and that they were treated with antibiotics. The Veteran had hesitancy of urine and a decreased force of stream. See September 2014 VA Examination. (17) Medical records from 2009 showing that the Veteran was told he had a leaking valve in his penis at one point. See June 2014 Medical Treatment Record. (18) The Veteran’s report that he originally had a UTI when he had right epididymitis during service. Every now and then, it was difficult to urinate and there was discoloration of his urine. The Veteran used antibiotics to clear up the problem. See May 2012 Hearing Testimony. (19) A medical record from 2010 showing the Veteran’s report that he had a UTI about once per year, which were treated with antibiotics. The Veteran reported recurrent UTIs since service. See December 2010 VA Examination. (20) Medical records from 2009 showing that other than the right testicle injury during service, the Veteran denied any other injury or trauma. See June 2009 Medical Treatment Record. (21) Medical records from 2009 showing that hypertension was diagnosed in the 1980s. See April 2009 Medical Treatment Record. (22) Service records showing an impression of a right inguinal hernia. See May 1999 Medical Treatment Record. (23) Service records showing that the Veteran was overweight, that the Veteran complained about being hit in the groin while playing basketball, and the right epididymitis and right testicular atrophy issues. See December 1997 STR. (24) Medical records from 1999 and 2003 showing that the Veteran was overweight. See August 2004 Medical Treatment Record; September 2003 Medical Treatment Record. (25) All other relevant lay and medical evidence. A complete rationale for all opinions offered should be provided. Address the Veteran’s documented history and assertions, including but not limited to, reports of continuity of symptomatology since service. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community’s knowledge or due to the limits of the examiner’s medical knowledge. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 3. Readjudicate the issue on appeal. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Dougan, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.