Citation Nr: 21065417 Decision Date: 10/26/21 Archive Date: 10/26/21 DOCKET NO. 17-42 494 DATE: October 26, 2021 REMANDED The issue of service connection for rectocele is remanded. The issue of service connection for uterine prolapse is remanded. REASONS FOR REMAND The Veteran had active service from August 1978 to August 2001. The issues of service connection for bilateral fallen arches and an increased rating for allergic rhinitis are no longer part of this appeal. In May 2020, the Veteran filed notices of disagreement (NODs) and elected to have those issues decided under the Appeals Modernization Act (AMA) system. Those two (2) issues will be decided in separate decisions under the AMA framework. In January 2021, the Veteran's representative asserted that the April 2020 left hip bursitis evaluation was on appeal. However, the Veteran did not perfect an appeal of that issue by filing a timely NOD under either the legacy or AMA systems. Therefore, the left hip bursitis evaluation is not before the Board. The Board of Veterans' Appeals (Board) has determined additional development is necessary and will remand the matters for the following actions: 1. BACKGROUND FOR THE RO ADJUDICATOR: This is a remand under Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Court or the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders). In November 2019, the Board remanded the issues of service connection for rectocele and uterine prolapse and directed the VA Regional Office (RO) to obtain a medical opinion addressing whether those conditions were caused by: (1) two in-service childbirths and any related complications; and/or (2) complications of an IUD removal during service. The opinion obtained in April 2020 did not fully respond to the Board's remand instructions. The examiner addressed the IUD removal but did not give an opinion whether the two in-service births caused the Veteran's rectocele and uterine prolapse. The examiner noted parity was a risk factor of developing rectocele but did not address the Veteran's two childbirths. Remand is necessary for an addendum opinion. 2. REMAND DIRECTIVES: Obtain an addendum from the examiner who provided the April 2020 VA opinion. If she is unavailable, obtain an opinion from another qualified PHYSICIAN. The examiner must give a thorough explanation for their opinions. The examiner is requested to give the following opinions: (1) Was the Veteran's rectocele caused by her two in-service childbirths, or any other disease, injury or event that occurred during service? (2) Was the Veteran's uterine prolapse caused by her two in-service childbirths, or any other disease, injury or event that occurred during service? (3) THE EXAMINER MUST ALSO EXPRESS AN OPINION WHETHER THE VETERAN'S ACCOUNT OF THE DEVELOPMENT OF HER RECTOCELE AND UTERINE PROLAPSE IS CONSISTENT WITH THE MEDICAL EVIDENCE AND THE EXAMINER'S KNOWLEDGE AND PRACTICE EXPERIENCE. The examiner must review the entire claim file; however the record indicates: *The Veteran's service treatment records (STRs) do not reflect that she was diagnosed with rectocele or a prolapsed uterus during service. Neither condition was noted in her annual in-service gynecological pelvic examinations. *The Veteran contends that rectocele and uterine prolapse were present after the births of her two children (in September 1980 and April 1983). She contends these conditions gradually worsened and continued with symptoms of urinary frequency and difficulty voiding her bowels. The Veteran reports that she began having "a sensation of fullness," urinary frequency, nocturia, and difficulty voiding in November 1995. *In June 1979, the Veteran reported "contraction-like pains" in her lower abdomen and small amounts of vaginal bleeding. On physical examination, her uterus was mobile and was not enlarged. The attending clinician's impression was "late menses vs. incomplete [abortion]," but noted pelvic tuberculosis had not been ruled out. *On June 23, 1979, the Veteran reported to the emergency room for "spotting, cramping, sharp abdominal pain in RLQ." She reported feeling something ""drop" in vagina ... or "POD." In the ER, she was noted to have blood clots in the vagina and "os." Uterus size was normal during pelvic examination. *In July 1979, the Veteran continued to report lower abdominal pain and an exploratory laparoscopy was performed. Pelvic examination revealed the Veteran's uterus was anteverted and had normal shape, size and contour. The attending clinician's impression was "probable pelvic inflammatory disease, low grade," and indicated pelvic tuberculosis was unlikely. *The Veteran gave birth to her first child in September 1980. Birth records noted the Veteran had a spontaneous vaginal delivery without complications. Her perineum was intact after birth and she did not have an episiotomy. The Veteran's postpartum course was initially noted to be "essentially unremarkable" and her bowel, bladder, and dietary activity returned to normal. *In an October 1980 postpartum checkup, the Veteran reported vaginal bleeding and fatigue. Pelvic examination revealed slight bleeding and a slightly enlarged uterus. The attending physician diagnosed postpartum subinvolution as a complication of childbirth. *A November 1980 obstetrical record noted the Veteran's uterus was retroflexed but had begun shrinking to its normal size. *In an April 1981 report of medical history, the Veteran reported being in good health and denied "frequent or painful urination," or treatment for a "female disorder." She continued to deny these symptoms/conditions in August 1992, February 1998. *During a December 1981 pelvic examination, the Veteran's uterus was anteflexed (tilted forward) and was noted to have normal size, shape, and position. No rectal examination was performed. *In March 1982, the Veteran reported sharp abdominal pain in the right lower quadrant ("RLQ"). On physical examination, the Veteran's uterus was normal. The attending physician noted mild adnexal tenderness but no specific masses. His impression was a probable benign ovarian cyst. *The Veteran gave birth to her second child in April 1983. A May 1983 postpartum record noted the Veteran was still reporting right lower abdominal pain. Pelvic examination revealed a retroverted/retroflexed ("RFRV") uterus. *A June 1983 chronological record of care noted a copper intrauterine device (IUD) was inserted "with difficulty on RF RV uterus." However, in a September 1984 clinical record, the Veteran denied any problems associated with IUD placement. Pelvic examination revealed a normal uterus with no masses. *The Veteran's IUD was removed in November 1985. A pelvic examination at the time of the procedure revealed a "somewhat fibrotic cervix," an anteflexed, normal-sized uterus, and unremarkable adnexa. *During a January 1987 routine pelvic examination, the uterine corpus was noted as normal in size and position, there were no rectal masses or tenderness, and no abnormalities were noted. *The Veteran had normal pelvic examinations during annual gynecological visits in 1988 and 1989. The cervix, vagina, uterus, and rectovaginal pouch were noted to be normal, and the uterus had normal size, shape, and contour. *In April 1992, the Veteran reported recurrent pelvic pain and a sensation of "pelvic fullness." The attending physician noted the uterus had normal size and contour of surfaces. An ultrasound was negative for any pelvic masses. *A November 1992 PAP test and biopsy indicated "benign endometrial tissue" and "constant and chronic inflammation." *In a November 1995 orthopedic record, the Veteran reported low back pain and a "sensation of fullness after voiding." She denied dysuria but reported increased urinary frequency and nocturia. She denied bowel or sexual dysfunction. The attending clinician noted a genitourinary exam was "not clinically indicated." The clinician's impression was "spondylosis vs. facet irritation vs. mechanical LBP." *In her April 2001 retirement physical, the Veteran reported frequent urination of unknown cause that was not responsive to Detrol. The attending clinician noted that a colposcopy and cone biopsy were performed in 1992 due to an abnormal PAP test. However, subsequent annual PAP tests were normal. *In a May 2001 compensation and pension examination, the Veteran reported having an "overactive bladder" for about six years (since approximately 1995). She reported that Detrol helped alleviate her urinary symptoms. The Veteran did not report any bowel symptoms at that time. The examiner diagnosed "mild" stress incontinence. *During a June 2006 annual PAP test, the Veteran reported she was concerned she may have a cystocele or rectocele. She reported feeling "like something may fall out" when occasionally needing to bear down with bowel movements. However, the Veteran denied changes in bowel or bladder function, dysuria, or painful intercourse. No cystocele or rectocele were detected on pelvic examination, and the Veteran's uterus was normal in size and position. *In a January 2008 women's health consultation, the Veteran denied urinary frequency and incontinence. Pelvic examination indicated her uterus had normal size and contour, without palpable masses or tenderness to palpation. *In November 2010, the Veteran denied dysuria and painful intercourse. Pelvic examinations in November 2010 and January 2011 revealed the uterus was in a normal position. No uterine prolapse, cystocele, or rectocele were observed during these examinations. The Veteran was perimenopausal. *A November 2012 VA medical record noted the Veteran was told she had cystocele and a prolapsed uterus in October 2012. She reported abdominal bloating, distension, and cramps in the right lower quadrant (RLQ). She reported gaining 12 pounds since August 2012. The attending clinician noted the Veteran had "symptomatic" menopause with vasomotor symptoms. *In December 2012, the Veteran continued to report an increase in abdominal bloating and weight gain in the past three months. She denied vaginal bleeding, dysuria, urine leakage, or any other gynecological problem. Pelvic examination was normal. *An October 2013 VA medical record noted diagnoses of cystocele and rectocele with "significant nocturia," and "irritable bowel syndrome." The Veteran reported difficulty voiding during bowel movements and using a splint to assist with voiding. The attending clinician noted an "extensive" workup was completed in 2012, including pelvic ultrasound, an abdominal/pelvic CT scan, and GI evaluation (colonoscopy, EGD, and MRCP). The clinician indicated that no inflammatory bowel disease or other source for the Veteran's abdominal discomfort was found. *The Veteran was diagnosed with stage II rectocele and cystocele in November 2013. She reported that these conditions were not bothersome and her major concern was urinary frequency. In December 2013, she reported having a "vaginal bulge" for several years. *A December 2014 VA medical record noted the Veteran was postmenopausal since 2011 with known stage II prolapse with recto and cystoceles. The Veteran denied preexisting symptoms from fibroids including lower pelvic pain or pressure. *During a 2017 VA urinary conditions examination, the Veteran reported she began having urinary frequency in the "mid 90's" and was advised to do Kegel exercises and take Ditropan. *A March 2020 VA medical record noted the Veteran had an approximate 20-year history of urinary frequency and constipation "due to rectocele/cystocele/bladder prolapse." The Veteran reported increasing urinary frequency and needing to manually push on her stomach to completely void her bowels. 3. If the RO continues to deny the claims, it should issue a Supplemental Statement of the Case (SSOC) and give the Veteran and her representative a reasonable opportunity to respond to the SSOC before returning the appeal to the Board. (CONTINUED ON NEXT PAGE) The Veteran has the right to submit additional evidence and argument on the matter or matters the Board remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Hiaasen The Board's decision is only binding in this case. This action is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.