Citation Nr: 21067856 Decision Date: 11/05/21 Archive Date: 11/05/21 DOCKET NO. 16-45 257 DATE: November 5, 2021 ORDER Entitlement to service connection for erectile dysfunction due to service-connected posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for obstructive sleep apnea and central sleep apnea due to service-connected PTSD is denied. Entitlement to service connection for a gastrointestinal disorder, to include gastroesophageal reflux disease (GERD), acid reflux, hiatal hernia, and Barrett's esophagitis, due to service-connected PTSD is denied. Entitlement to service connection for benign neoplasms and colon polyps is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the erectile dysfunction is etiologically related to service-connected PTSD. 2. The preponderance of the evidence is against a finding that the obstructive sleep apnea and central sleep apnea are etiologically related to service-connected PTSD. 3. The preponderance of the evidenced is against a finding that the GERD, acid reflux, hiatal hernia, and Barrett's esophagitis are etiologically related to service-connected PTSD. 4. The Veteran does not have a diagnosis of benign neoplasms or colon polyps at any point during the appeal period. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for erectile dysfunction due to service-connected PTSD have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303, 3.310. 2. The criteria for entitlement to service connection for sleep apnea due to service-connected PTSD have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303, 3.310. 3. The criteria for entitlement to service connection for a gastrointestinal disorder, to include GERD, acid reflux, hiatal hernia, and Barrett's esophagitis, due to service-connected PTSD have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303, 3.310. 4. The criteria for entitlement to service connection for benign neoplasms have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1970 to October 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from November 2015 and August 2016 rating decisions of the Department of Veteran Affairs (VA) Regional Office (RO). These issues were previously before the Board in January 2019 when service connection for each claim was denied. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court), and in a June 2020 Memorandum Decision, the Court vacated the January 2019 Board decision with respect to the issues above. The Court held that the Board erred in relying on a medical opinion that only addressed the diagnosis of obstructive sleep apnea, and not the diagnosis of central sleep apnea. As the same medical examiner that wrote the sleep apnea opinion also wrote the opinions for the remaining claims, the Court found that the adequacy of those opinions was also impacted. These issues returned to the Board in December 2020 when they were remanded for further development. That development was completed and the case has returned to the Board for appellate review. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (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 or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). In addition, service connection for certain chronic diseases may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 1. Entitlement to service connection for erectile dysfunction due to service-connected PTSD The Veteran alleges that the erectile dysfunction is due to the service-connected PTSD. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). An October 2015 VA examination confirms a diagnosis of erectile dysfunction. Numerous VA treatment records indicate that the Veteran takes medication for the erectile disorder. Accordingly, the first element of service connection is met. Second, the Board finds that there was an in-service disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran's service treatment records (STRs), including the September 1969 induction examination and October 1971 separation examination, are silent for any complaints of or treatment for erectile dysfunction. However, as the Veteran has asserted that the erectile dysfunction is due to the service-connected PTSD, the second element of service connection is met. Third, the Board finds that the evidence of record does not support a finding that the erectile dysfunction is related to active service. The Veteran underwent a VA examination in October 2015 where the examiner provided a negative nexus opinion. On the examination, the examiner noted that the erectile dysfunction etiology is natural aging and hyperlipidemia. The examiner opined that a review of current medical literature and research shows no physiologic or biomechanical causal relationship between mental health conditions such as PTSD and the physiologic condition erectile dysfunction. The examiner explained that in most cases, erectile dysfunction is caused by something physical, and noted that common causes include heart disease, atherosclerosis, high cholesterol, high blood pressure, diabetes, and obesity. In December 2016, the Veteran submitted medical literature suggesting a link between PTSD and erectile dysfunction. In March 2017, the RO obtained another VA medical opinion. The examiner provided a negative nexus opinion based on a review of the record, noting articles that the Veteran submitted regarding the connection between sexual dysfunction and PTSD, and explained that the articles are well-known but present no evidence that PTSD causes erectile dysfunction. The examiner stated that they suggest that there is an increased risk in erectile dysfunction and people with PTSD. However, the examiner explained that the Veteran has many more significant risk factors for the development of erectile dysfunction, including hypertension, a high body mass index, hypercholesterolemia, hypothyroidism, and a history of tobacco use. The examiner opined that there is no evidence PTSD has caused or permanently aggravated erectile dysfunction beyond its natural progression. The Veteran underwent another VA examination in August 2021 where the examiner provided a negative nexus opinion. The examiner noted that medical records documented impotence of organic origin with an onset in January 2013, that the Veteran has a documented diagnosis of hyperlipidemia dating back to at least 2013, and that there is a comorbid diagnosis of hypothyroidism. The examiner stated that the etiology of erectile dysfunction is multi-factorial to include both of those conditions. Citing to relevant medical literature, the examiner explained that epidemiologic data has confirmed that hyperlipidemia is a strong independent risk factor for the development of erectile dysfunction via endothelial damage and inflammation. The examiner stated that research has also found hypothyroidism to be a strong contributing factor for erectile dysfunction. Finally, the examiner explained that aging and decreased testosterone levels are also known to contribute to erectile dysfunction. The Board affords the August 2021 VA medical opinion great probative value. It reflects a careful consideration of the record and the Veteran's assertion that the erectile dysfunction is due to the service-connected PTSD, and is supported by well-reasoned rationale and relevant medical literature. Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The Board also affords probative value to the March 2017 VA medical opinion. While similar to the October 2015 and August 2021 VA opinions in reasoning and rationale, the examiner cited to the incorrect legal standard and opined that the condition had clearly and unmistakably existed prior to service, and was not aggravated beyond its natural progression by an in-service event, injury, or illness. However, the Board finds it likely that the examiner merely selected the wrong option, especially given that the content of the opinion is clearly reflective of a secondary service connection claim addressing both causation and aggravation, and that the record does not reflect a diagnosis, complaint of, or arguments for erectile dysfunction prior to service. At no point in the opinion does the examiner discuss erectile dysfunction as a pre-existing condition. The Board affords the October 2015 less probative value. While similar in reasoning and rationale to the other opinions, the examiner did not address aggravation. In a secondary service connection claim, a medical opinion that a disorder is not the result of an already service-connected disability does not address the issue of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). The Board has also considered the Veteran's statements in support of their claim. While the Veteran is competent to report on their symptoms, the Board finds the Veteran not competent to offer an opinion as to whether the erectile dysfunction is related to any instance of their service since the record does not indicate that they possess the requisite medical knowledge to offer such an opinion. Specifically, the etiology of such disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as such is a complex medical question, the Veteran is not competent to offer an opinion as to the etiology of the erectile dysfunction, and, consequently, their opinion on such matters is afforded no probative weight. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Veteran has submitted an article in support of a link between the erectile dysfunction and PTSD. The Court has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if 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. Mattern v. West, 12 Vet. App. 222, 228 (1999). However, the medical study evidence submitted by the Veteran is not accompanied by the opinion of any medical expert. Moreover, VA actually obtained a medical opinion of record to review the article, but the obtained opinion was against the Veteran's claim. The Board understands the Veteran's arguments and has reviewed the article he submitted. However, the article does not overcome the medical evidence of record that is directly on point in this case. The Board has also considered whether presumptive service connection can be established where there is evidence of continuity of symptomology of a chronic condition since service. See 38 C.F.R. § 3.309. However, erectile dysfunction is not a chronic condition under 38 C.F.R. § 3.309, and the record of evidence does not show a diagnosis until many years following separation from active-duty service. Therefore, consideration based on presumptive service connection for continuity of symptomatology is not warranted. As there is no other medical opinion or any competent and credible evidence in significant conflict with the VA examiner's opinion, the Board finds that the preponderance of the evidence is against a finding that the Veteran's erectile dysfunction is related to military service. Accordingly, service connection is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for sleep apnea due to service-connected PTSD The Veteran alleges that sleep apnea is due to service-connected PTSD. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). A sleep study in October 2015 noted diagnoses of obstructive sleep apnea and central sleep apnea. Accordingly, the first element of service connection is met. Second, the Board finds that there was an in-service disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran's STRs, including the September 1969 induction examination and October 1971 separation examination, are silent for any complaints of or treatment for any sleep related issues. However, as the Veteran has asserted that the sleep apnea is due to the service-connected PTSD, the second element of service connection is met. Third, the Board finds that the evidence of record does not support a finding that the sleep apnea is related to active service. The Veteran underwent a VA examination in October 2015 where the examiner provided a negative nexus opinion as at that time there had not yet a diagnosis of sleep apnea. The RO obtained a new VA medical opinion in August 2016 based on a review of the record. The examiner explained that a review of the current medical literature and research shows no physiologic or biomechanical causal relationship between a mental health condition such as PTSD and the physiologic condition of sleep apnea. The examiner stated that PTSD is not an accepted cause of obstructive sleep apnea in the generally recognized medical literature. The examiner explained that there is ample opportunity for confusion because both disorders cause disruption of sleep and can cause traumatic awakenings; however, the two disorders are totally different and do not affect the natural history of the other. The examiner stated that sleep apnea is due to obesity, and that obesity is caused by excessive caloric intake and reduced caloric expenditure which is a choice. The examiner opined that PTSD does not cause obesity. The Veteran underwent a new VA examination in August 2021 where the examiner provided a negative nexus opinion. The examiner opined that it is less likely than not that obstructive sleep apnea is caused or aggravated by PTSD. Citing to relevant medical literature, the examiner explained that obstructive sleep apnea is due to anatomic factors that promote pharyngeal narrowing, including large neck circumference, cervical soft tissue, vessels, and bony structures. The examiner stated that research and data have shown that untreated obstructive sleep apnea may exacerbate symptoms of PTSD and depression; however, although these are common comorbid conditions, there is no evidence to support an etiopathogenic relationship between PTSD and the development of obstructive sleep apnea. The examiner explained that the pathophysiology of obstructive sleep apnea is upper airway collapse during sleep, which leads to fragmented sleep and reduced flow of oxygen to the brain. The examiner also opined that it is less likely than not that the central sleep apnea is caused or aggravated by PTSD. The examiner explained that there is no demonstrated etiopathogenic relationship between PTSD or any other psychiatric condition and the development of idiopathic central sleep apnea. The examiner stated that central sleep apnea occurs because of a problem in the brain stem where signals are not transmitted effectively to the muscles of respiration, including the diaphragm. The Board affords the August 2021 VA medical opinion great probative value. It reflects a careful consideration of the record (including both diagnoses of obstructive and central sleep apnea) and the Veteran's assertion that the sleep apnea is due to the service-connected PTSD, and is supported by well-reasoned rationale and relevant medical literature. Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion. Prejean, 13 Vet. App. at 448-9. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez, 22 Vet. App. at 301. The Board affords low probative value to the August 2016 VA medical opinion. While the examiner arrived at a similar opinion using similar supporting rationale as the August 2021 VA medical opinion, the examiner did not address the diagnosis of central sleep apnea. Although a Veteran may identify a particular disorder when they a claim, the scope of the claim cannot be limited only to the disorder stated, but must be considered a claim for any disorder that may reasonably be encompassed by several factors including the description of the claim, the symptoms the claimant describes, and the information the claimant submits or that VA obtains in support of the claim. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Additionally, while it addressed causation, it did not address aggravation. In a secondary service connection claim, a medical opinion that a disorder is not the result of an already service-connected disability does not address the issue of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). The Board has also considered the Veteran's statements in support of their claim. While the Veteran is competent to report on their symptoms, the Board finds the Veteran not competent to offer an opinion as to whether the sleep apnea is related to any instance of their service since the record does not indicate that they possess the requisite medical knowledge to offer such an opinion. Specifically, the etiology of such disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as such is a complex medical question, the Veteran is not competent to offer an opinion as to the etiology of the sleep apnea, and, consequently, their opinion on such matters is afforded no probative weight. Woehlaert, 21 Vet. App. at 456. The Board has also considered whether presumptive service connection can be established where there is evidence of continuity of symptomology of a chronic condition since service. See 38 C.F.R. § 3.309. However, sleep apnea is not a chronic condition under 38 C.F.R. § 3.309, and the record of evidence does not show a diagnosis until many years following separation from active-duty service. Therefore, consideration based on presumptive service connection for continuity of symptomatology is not warranted. As there is no other medical opinion or any competent and credible evidence in significant conflict with the VA examiner's opinion, the Board finds that the preponderance of the evidence is against a finding that the Veteran's obstructive sleep apnea and central sleep apnea are related to military service. Accordingly, service connection is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert, 1 Vet. App. at 49. 3. Entitlement to service connection for a gastrointestinal disorder, to include GERD, acid reflux, hiatal hernia, and Barrett's esophagitis, due to service-connected PTSD The Veteran alleges that their gastrointestinal disorders are related to the service-connected PTSD. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). An October 2015 VA examination noted diagnoses of GERD, hiatal hernia, and Barrett's esophagitis. Accordingly, the first element of service connection is met. Second, the Board finds that there was an in-service disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran's STRs, including the September 1969 induction examination and October 1971 separation examination, are silent for any complaints of or treatment for any gastrointestinal issues. However, as the Veteran has asserted that the gastrointestinal disorders are due to the service-connected PTSD, the second element of service connection is met. Third, the Board finds that the evidence of record does not support a finding that the gastrointestinal disorders are related to active service. The Veteran underwent a VA examination in October 2015 where the examiner provided a negative nexus opinion. The examiner explained that the Veteran did not take PTSD medication, and that a review of medical literature found no support that PTSD causes GERD, or acid reflux. In December 2016, the Veteran submitted medical literature suggesting a link between PTSD and certain gastrointestinal conditions, to include GERD and acid reflux. The RO subsequently obtained a new VA medical opinion in March 2017. There, the examiner provided a negative nexus opinion. The examiner reviewed the articles and explained that while they are well-known, they present no evidence that PTSD causes GERD, but rather simply suggest an increased risk for GERD and individuals with PTSD. The examiner stated that the Veteran has significant other conditions that put them at greater risk for GERD such as hiatal hernia and a high body mass index. The examiner opined that there is no evidence that PTSD caused or permanently aggravated GERD beyond its natural progression. The examiner also noted the presence of Barrett's esophagitis. The Veteran underwent a new VA examination in August 2021 where the examiner provided a negative nexus opinion. The examiner explained that the GERD is secondary to the hiatal hernia, and that the Barrett's esophagitis is secondary to the GERD. The examiner opined that it is less likely than not that the hiatal hernia is caused or aggravated by the PTSD. The examiner explained that there is no etiopathogenic relationship between a hiatal hernia and PTSD. The examiner stated that hiatal hernias may be congenital or acquired with an increased prevalence in those over 50 years of age, and that muscle weakness with loss of flexibility and elasticity with age predispose to the development of a hiatal hernia. The examiner explained that this may cause the upper part of the stomach to not return to its natural position below the diaphragm during swallowing. Finally, the examiner noted that obesity, age, trauma, previous surgeries, and genetics factor into the development of hiatal hernias. The Board affords the August 2021 VA medical opinion great probative value. It reflects a thorough review of the record, and is supported by well-reasoned rationale and relevant medical literature. Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). It also addresses each diagnosis of record. See Clemons, 23 Vet. App. at 5. The Board affords the October 2015 and March 2017 VA medical opinions low probative value as both failed to address all diagnoses of record. While the October 2015 VA examination noted a diagnosis of hiatal hernia, the examiner did not address it in the medical opinion. And while the March 2017 VA examination noted Barrett's esophagitis, the examiner did not address that or the hiatal hernia in the medical opinion. The Board has also considered the Veteran's statements in support of their claim. While the Veteran is competent to report on their symptoms, the Board finds the Veteran not competent to offer an opinion as to whether the gastrointestinal disorders are related to any instance of their service since the record does not indicate that they possess the requisite medical knowledge to offer such an opinion. Specifically, the etiology of such disorders involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Therefore, as such is a complex medical question, the Veteran is not competent to offer an opinion as to the etiology gastrointestinal disorders, and, consequently, their opinion on such matters is afforded no probative weight. Woehlaert, 21 Vet. App. at 456. The Veteran has submitted an article in support of a link between the gastrointestinal disorder and PTSD. The Court has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if 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. Mattern, 12 Vet. App. at 228. However, the medical study evidence submitted by the Veteran is not accompanied by the opinion of any medical expert. Moreover, VA actually obtained a medical opinion of record to review the article, but the obtained opinion was against the Veteran's claim. The Board understands the Veteran's arguments and has reviewed the article they submitted. However, the article does not overcome the medical evidence of record that is directly on point in this case. The Board has also considered whether presumptive service connection can be established where there is evidence of continuity of symptomology of a chronic condition since service. See 38 C.F.R. § 3.309. However, gastrointestinal disorders are not a chronic condition under 38 C.F.R. § 3.309, and the record of evidence does not show a diagnosis until many years following separation from active-duty service. Therefore, consideration based on presumptive service connection for continuity of symptomatology is not warranted. As there is no other medical opinion or any competent and credible evidence in significant conflict with the VA examiner's opinion, the Board finds that the preponderance of the evidence is against a finding that the Veteran's gastrointestinal disorders are related to military service. Accordingly, service connection is denied. Accordingly, service connection is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for benign neoplasms The Veteran alleges that benign neoplasms or colon polyps are due to the service-connected PTSD. (Continued on the next page) The Board finds that there is not a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran underwent a VA examination in October 2015 where the examiner found that there was no diagnosis for benign neoplasms or colon polyps. The examiner noted the Veteran's reports of a history of bright red blood with bowel movements once a month for 10 years. The examiner explained that the Veteran had a colonoscopy which found polyps that were removed in 2006 or 2007, but that there were no further polyps. The examiner indicated no benign malignant neoplasm or metastases. The Board notes VA treatment records that also indicate negative findings for colon polyps, including in February 2019, September 2020, and June 2021. As the record indicates that the Veteran has not had benign neoplasms or colon polyps at any point during the appeal period, there is no disability upon which service connection may be granted. Accordingly, service connection is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rogos 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.