Citation Nr: 21004755 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 15-42 768A DATE: January 28, 2021 ORDER Service connection for penile shortening is denied. FINDINGS OF FACT 1. The Veteran had active service from December 1965 to November 1967; he has been 100 percent disabled based on unemployability since January 2018. 2. Penile shortening was not shown in service, is not causally or etiologically related to service, and was not caused by or permanently worsened in severity by a service-connected disability. CONCLUSIONS OF LAW Penile shortening was not incurred in service and is not proximately due to, aggravated by, or the result of a service-connected disability. 38 U.S.C. §§ 1110, 1131, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In September 2018, the Board denied service connection for penile shortening secondary to service-connected prostate cancer. The Veteran appealed to the Veterans Claims Court. In May 2020, the Court issued a Memorandum Decision, which served to both vacate the September 2018 Board decision and remand the claim for service connection for penile shortening to the Board for action consistent with the Memorandum Decision. Service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran has asserted that his penile shortening is caused by treatment for service-connected prostate cancer. He has specifically limited consideration for service connection as secondary due to service-connected prostate cancer in a November 2015 supplemental claim for compensation. In this regard, he does not assert, and the evidence does not show, that his claimed disability began in service, or is otherwise related to active service. As such, direct service connection is not for application. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008) (claims which have no support in the record need not be considered by the Board as the Board is not obligated to consider “all possible” substantive theories of entitlement). With regard to secondary service connection, the record shows that the Veteran was diagnosed with penile shortening since 2010 on a March 2016 VA examination report. As such, a current disorder has been shown and the first element of secondary service connection is met. Next, he has been service-connected for prostate cancer since May 2010. As such the second element of secondary service connection, a service-connected disability, has also been met. Therefore, the remaining question before the Board is whether there is medical evidence establishing a link between the service-connected disability of prostate cancer, and the current penile shortening disability. In a March 2016 VA examination, the Veteran was diagnosed with penile shortening. The examiner opined that the Veteran’s penile shortening was not caused by his service-connected prostate cancer, status-postoperative radical prostatectomy because prostate removal does not incur removal of the testes or adrenal gland, and accordingly, does not reduce the male hormones unless associated with hormonal or chemotherapy which the Veteran did not undergo. In a November 2016 VA treatment record, a VA clinician indicated that penile shortening after a prostatectomy was “likely and somewhat expected.” In a January 2017 VA addendum record, the November 2016 VA physician’s assistant indicated that “med records from MI urologist reviewed. There is no mentioning of possible penile shortening as a complication of [radical prostatectomy] and there is no discussion on the pre-op vs post-op length of the penis.” In an April 2017 VA treatment record, the clinician noted discussing “the issue of penile shortening after the [radical retropubic prostatectomy] - explained to the pt that there is no documentation in his outside records that [I] reviewed regarding pre/post op length, or measurements of the pt.” In support of his claim, the Veteran submitted two medical article abstracts in January 2017. The first medical article abstract showed complaints of “penile shortening following radical prostatectomy[, which] can be a devastating and unwelcome side effect.” The second medical article abstract noted complaints of penile shortening post radical prostatectomy “a median of 5.53 years after prostatectomy and concluded “complaints about a reduced penile size were more common with RT [radiotherapy] plus ADT [adrogen deprivation therapy] or surgery rather than RT alone.” After considering the totality of the evidence, the medical evidence weighs against the claim. In this regard, the Board has afforded great probative weight to the medical opinion provided at the March 2016 VA examination. The opinion was based on an examination of the Veteran as well as a review of his medical history and considered his contentions. Additionally, there is no evidence that any essential fact was misstated or improperly relied upon in rendering the opinion. Although a November 2016 VA treatment note related that penile shortening after a prostatectomy was “likely and somewhat expected;” however, in a January 2017 separate addendum entry, the clinician indicated that “med records from MI urologist reviewed” and “[t]here is no mentioning of possible penile shortening as a complication of [radical prostatectomy] and there is no discussion on the pre-op vs post-op length of the penis.” The Board finds that the November 2016 statement is less probative than the March 2016 VA examiner’s opinion as well as the January 2017 addendum entry. In the November 2016 treatment note, the VA clinician noted that penile shortening after a prostatectomy was likely and somewhat expected, however, she did not discuss the underlying medical reason, that is - shortening may be caused by hormonal treatment or chemotherapy because of the reduction of male hormones. As the Veteran’s operation did not reduce the male hormones (as found by the March 2016 VA examination), the clinician did not explain why the procedure would cause shortening. Further, in a January 2017 addendum note, the clinician clarified that, after reviewing the Veteran’s medical records, that there was no mention of possible penile shortening as a complication of a radical prostatectomy. This evidence weighs against the claim. The Board has also carefully considered the articles submitted by the Veteran regarding any causal relationship between penile shortening and prostate cancer. The Court has indicated that treatise evidence may suffice to establish nexus in instances where “standing alone, [it] 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.” Sacks v. West, 11 Vet. App. 314, 317 (1998). Significantly however, the Court has also held that treatise materials generally are not specific enough to show nexus, id. at 317, and that medical opinions directed at specific patients generally are more probative than medical treatises. Herlehy v. Brown, 4 Vet. App. 122, 123 (1993). In this situation, the March 2016 medical opinion addressed the Veteran’s specific case with references to his specific treatment, which is more probative than generic treatise evidence. Further, while medical treatise evidence can provide important support when combined with an opinion of a medical professional, such a medical nexus has not been provided. Mattern v. West, 12 Vet. App. 222, 228 (1999). Rather, the articles provided only a brief overview of the research studies without specifics to this Veteran’s situation nor were the complete research studies of record. As such, this evidence is not dispositive, is assigned lesser probative value, and does not outweigh the findings of the March 2016 VA opinion which was based on a specific examination of this Veteran. The Board has considered the Veteran’s lay statements that penile shortening was caused by treatment for service-connected prostate cancer. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the etiology of his current disorder due to the medical complexity of the matter involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board’s consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Grzeczkowicz 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.