Citation Nr: 21067359 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 16-61 915 DATE: November 4, 2021 ORDER Entitlement to a compensable rating for left varicocele is denied. FINDING OF FACT Throughout the period on appeal, the Veteran's left varicocele was manifested by, at worst, intermittent pain and swelling; it was not manifested by complete atrophy of either testis, removal of either testis, voiding dysfunction, renal dysfunction, erectile dysfunction, or urinary tract infection. CONCLUSION OF LAW The criteria for a compensable disability rating for left varicocele have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.115b, Diagnostic Code (DC) 7523. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1945 to April 1949. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the Veteran and his wife testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, this matter was previously before the Board in July 2020, when it was remanded for further development. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Entitlement to a compensable rating for left varicocele is denied. As an initial matter, the Veteran filed his claim for entitlement to a compensable rating for his service-connected left varicocele on February 11, 2015. See February 2015 VA Form 21-526EZ, Fully Developed Claim (Compensation). Throughout the period on appeal, the Veteran's left varicocele has been assigned a non-compensable disability rating pursuant to 38 C.F.R. § 4115b, DC 7523. Under DC 7523, a non-compensable rating is assigned for complete atrophy of one testis, and a 20 percent rating is assigned for complete atrophy of both testes. 38 C.F.R. § 4.115b, DC 7523. Atrophy is defined as "a wasting away; a diminution in the size of a cell, tissue, organ or part." See Dorland's Illustrated Medical Dictionary 157 (28th ed. 1994). Turning to the evidence of record, private treatment records dated in June and July 2013 show that the Veteran received a suspensory ligament support orthotic for his service-connected left varicocele. See December 2015 Medical Treatment Record Non-Government Facility. In a January 2015 letter, the Veteran reported that his left varicocele periodically ached and swelled. See February 2015 Correspondence. The Veteran underwent a VA examination for male reproductive system conditions in April 2015. The examiner noted that the Veteran had been diagnosed with a left varicocele. During the examination, the Veteran endorsed pain behind his left testicle, which occurred every other day. He further indicated that his left testicle swelled up and stated that there was a "bag of veins" therein. The examiner reported that the Veteran's treatment plan did not require continuous medication and stated that he had not had an orchiectomy. In addition, the examiner found that the Veteran's left varicocele did not result in renal, voiding, or erectile dysfunction, and his testes and epididymis were noted to be normal on physical examination. Following the examination, the examiner found that the Veteran's left varicocele impacted his ability to work. In this regard, the Veteran reported that he avoided bending over to put outlets in the wall due to intermittent scrotal pain when he worked as an electrician. However, he also stated that he last worked in this position in the 1990s. See April 2015 C&P examination. In November 2015, the Veteran stated that his left varicocele caused serious problems and indicated that it had interfered with his ability to work as an electrician. To this end, he reported that it impeded his ability to climb and crawl, even when he wore varicocele supports. The Veteran further reported that the VA examiner who performed his April 2015 VA examination was inexperienced, unfamiliar with his disability, and reluctant to touch his groin area during the examination. See December 2015 VA Form 21-4138 Statement in Support of Claim; see also August 2015 NOD. The Veteran also underwent a VA examination for male reproductive system conditions in September 2016. The examiner diagnosed the Veteran with a varicocele. During the examination, the Veteran endorsed intermittent symptoms. He further indicated that he had never had surgery for his varicocele and stated that he had two children. To this end, the Veteran denied problems with fertility. The examiner indicated that the Veteran's treatment plan did not require continuous medication and noted that he had not had an orchiectomy. In addition, the examiner found that the Veteran's left varicocele did not result in renal, voiding, or erectile dysfunction. On physical examination, the Veteran's testes were normal, but his epididymis was noted to be abnormal. Specifically, the examiner reported that the Veteran's entire left scrotum was tender to palpation. After performing an examination, the examiner found that the Veteran's left varicocele impacted his ability to work. In this regard, the Veteran endorsed constant pain, primarily while climbing up and down ladders, when he worked as an electrician. See September 2016 C&P examination. In December 2016, the Veteran indicated that he wore a belt to hold his testicles and reported that he experienced pain every other day due to his left varicocele. See December 2016 VA Form 646 Statement of Accredited Representative in Appealed Case. During the August 2019 Board hearing, the Veteran endorsed pain and testified that his left varicocele interfered with his ability to walk, sit, and climb ladders. He also indicated that his varicocele swelled when it was touched or bumped, which occurred approximately once per week, and his wife testified that the Veteran's left varicocele caused significant discomfort while he was working as an electrician. The Veteran further testified that he wore a supportive device and took Tylenol to manage his symptoms. In addition, the Veteran asserted that the examiner who performed his September 2016 VA examination was not a specialist and indicated that the examiner was afraid to touch him during the examination. See August 2019 Hearing Transcript, pages 4-5, 7-11, 15-17. In October 2019, the Veteran endorsed urinary incontinence and stated that he soiled his clothes when he sat down on and stood up from the commode. During the appointment, the Veteran stated that he had a varicocele and asked whether it could be the cause of his urinary symptoms. He also endorsed sexual dysfunction. See November 2019 CAPRI. In November 2020, the Veteran was noted to have benign prostatic hyperplasia with lower urinary tract symptoms. At that time, the examiner found that the Veteran had a history of frequent urinary tract infection symptoms, to include nocturia, which occurred two to three times per night. See January 2021 CAPRI. VA obtained an addendum medical opinion in February 2021. After performing a review of the evidence of record, the examiner opined that it was less likely than not that the Veteran's urinary leakage and erectile dysfunction symptoms were caused or aggravated beyond their normal progression by his service-connected left varicocele. In support of his opinion, the examiner noted that the Veteran was 94 years old and had been diagnosed with benign prostatic hyperplasia with urinary symptoms and a left varicocele. However, the examiner also noted that the Veteran had never undergone surgical intervention to reduce his left varicocele. To this end, the examiner found that the Veteran's urinary incontinence and sexual dysfunction were caused by his age and by his benign prostatic hyperplasia, which was most closely related to his complaints of urinary leakage and erectile dysfunction. The examiner further stated that, even in the absence of a benign prostatic hyperplasia diagnosis, the Veteran would experience urinary leakage and erectile dysfunction due to his senescence. As such, the examiner opined that it was less likely than not that the Veteran's the urinary leakage and erectile dysfunction symptoms were related to his service-connected left varicocele. See February 2021 C&P examination. After a review of the evidence of record, the Board finds that a compensable disability rating for the Veteran's service-connected left varicocele is not warranted. To this end, the record does not show that the Veteran's left varicocele resulted in complete atrophy of either testis, removal of either testis, voiding dysfunction, renal dysfunction, erectile dysfunction, or urinary tract infection. To the contrary, the April 2015 and September 2016 VA examiners both found the Veteran's testes to be normal, and subsequent medical treatment records do not reflect any evidence of testicular atrophy. See April 2015 C&P examination; September 2016 C&P examination; July 2020 CAPRI; January 2021 CAPRI. Thus, the Board finds that a compensable rating for the Veteran's service-connected left varicocele is not warranted under DC 7523. The Board recognizes the Veteran's statements that his urinary incontinence and sexual dysfunction symptoms may be related to his service-connected left varicocele. However, the Veteran has not been shown to be competent to relate such symptoms to his service-connected disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the Board notes that the Veteran endorsed urinary incontinence and sexual dysfunction in October 2019. At that time, the Veteran also stated that he had a varicocele and asked whether it could be the cause of such symptoms. See November 2019 CAPRI. However, a subsequent November 2020 medical treatment records shows that the Veteran's lower urinary tract symptoms were associated with his diagnosed benign prostatic hyperplasia, and in the February 2021 addendum medical opinion, the VA examiner opined that it was less likely than not that the Veteran's urinary leakage and erectile dysfunction symptoms were caused or aggravated beyond their normal progression by his service-connected left varicocele. See January 2021 CAPRI; February 2021 C&P examination. Thus, the Board concludes that the Veteran's lay assertions are outweighed by the medical evidence of record, to include to February 2021 addendum medical opinion and the cumulative medical evidence of record. The examiners have the training, knowledge, and expertise on which they relied to form their opinions and provided a persuasive rationale to support the conclusions reached. Importantly, there is no competent medical evidence to the contrary. The Board has also considered whether a higher initial rating is warranted under any other diagnostic code. See Schafrath v. Derwinski,1 Vet. App. 589, 595 (1991). To this end, the Board notes that, under DC 7524, a noncompensable rating is assigned for removal of one testis, and a maximum 30 percent rating is warranted for removal of both testes. 38 C.F.R. § 4.115b, DC 7524. However, the Board notes that the Veteran has not argued, and the evidence of record does not suggest, that either of his testicles have been removed. Rather, the evidence shows that the Veteran has never had surgical intervention to reduce his left varicocele. See, e.g., February 2021 C&P examination. As such, DC 7524 is not for application. In addition, the Board has considered the Veteran's complaints of testicular pain but, for the reasons stated above, finds that his service-connected left varicocele is properly rated under DC 7523 for atrophy of the testis. In this regard, while pain is not specifically listed in the rating criteria, pain is often a symptom of varicocele. See mayoclinic.org; nationaltesticularcancersociety.org. Thus, in the absence of urinary tract infection or renal or voiding dysfunction associated with varicocele, the Veteran's symptoms of pain, tenderness, and swelling are most appropriately rated under DC 7523. 38 C.F.R. § 4.115b. To this end, the Board emphasizes that the Veteran would not be entitled to a separate or higher rating under any other diagnostic code. In addition, the Board recognizes the Veteran's assertion that the April 2015 VA examination was not good or detailed and that the examiner who performed the examination was reluctant to touch him during the examination. See August 2015 NOD; December 2015 VA Form 21-4138 Statement in Support of Claim. The Board further notes that, during the August 2019 Board hearing, the Veteran testified that the September 2016 VA examiner was also afraid to touch him. See August 2019 Hearing Transcript, pages 7-9. To the extent the Veteran may argue or suggest that the April 2015 and September 2016 VA examinations are inadequate, the Board finds such arguments unpersuasive. To this end, there is no indication, other than the Veteran's assertion, that the April 2015 and September 2016 VA examinations were not detailed or adequate. To the contrary, the examination reports reflect that the examiners identified relevant symptoms, physically examined the Veteran's penis, testes, and epididymis, and documented the symptomatology and functional impairment described by the Veteran at the time of each examination. See April 2015 C&P examination; September 2016 C&P examination. Accordingly, the record does not reflect that the VA examinations were inadequate. Lastly, the Board recognizes the Veteran's report that the September 2016 VA examination was not performed by a specialist. See August 2019 Hearing Transcript, pages 7-9. In this regard, the Board notes that the September 2016 VA examination was performed by a physician's assistant (PA). See September 2016 C&P examination. The Board notes that, by itself, the fact that the September 2016 VA examiner was a PA does not render the examiner unqualified or the examination inadequate. See e.g., Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (VA satisfied its duty to assist when it provided a medical examination performed by a person who is qualified through education, training, or experience to offer medical diagnosis, statements, or opinions able to provide competent medical evidence, whether that is a doctor, nurse practitioner or PA.). To this end, a PA may generally be considered as qualified through education, training and/or experience to offer medical diagnoses and opinions. Thus, in the absence of any specific objection to the competence of the examiner (other than that he is a PA), the Board finds that the examiner who performed the September 2016 VA examination was competent to do so in this case. See Cox v. Nicholson, 20 Vet. App. 563, 569 (2007); Francway v. Wilkie, 940 F.3d 1304 (Fed. Cir. 2019). Based on the foregoing, the Board finds that the preponderance of the evidence is against assignment of a compensable rating for the Veteran's service-connected left varicocele at any time during the period on appeal. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.115b; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.