Citation Nr: 21069044 Decision Date: 11/17/21 Archive Date: 11/17/21 DOCKET NO. 16-27 139 DATE: November 17, 2021 ORDER Service connection for Peyronie's disease is granted. FINDING OF FACT The Veteran's Peyronie's disease cannot be satisfactorily disassociated from his active service. CONCLUSION OF LAW With all reasonable doubt resolved in the Veteran's favor, the criteria for entitlement to service connection for Peyronie's disease have been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from January 1976 to February 1997. This matter is before the Board of Veterans' Appeals (the Board) on appeal from a May 2012 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. The rating decision, inter alia, denied service connection for Peyronie's disease. The Veteran's Notice of Disagreement (NOD) was received in July 2012. The Statement of the Case (SOC) was issued in May 2016, and the Veteran's VA Form 9, substantive appeal to the Board was received in June 2016. In July 2019, the Veteran and his representative appeared before the undersigned Veterans Law Judge (VLJ) for a Board video hearing. The transcript is of record. The Board remanded the claim in October 2019 and May 2021. Entitlement to service connection for Peyronie's disease. The Veteran contends that Peyronie's disease had its onset in service. He identified a diving incident as the in-service injury that caused his disability. Alternatively, the Veteran contends that Peyronie's disease had its onset in service following an optional circumcision. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 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 occurrence 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). It is the Board's responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The Veteran's service treatment records do not contain a diagnosis or treatment for Peyronie's disease. An August 1977 treatment note indicates that the Veteran complained of back pain after diving into the pool. It was noted that his head did not strike the bottom, but that he had muscle spasms and soreness, along with decreased range of motion due to pain at L3-4 level. He was noted to have an acute muscle strain. A follow up note on the next date indicated that the Veteran was much improved from back spasms and was recommended light duty for 24 hours. A February 1986 treatment note indicates that the Veteran sought an elective circumcision for hygienic and aesthetic reasons. There were no problems noted and the Veteran was referred to neurology. A June 1987 treatment note indicates that the Veteran complained of anterior pelvic pain and sensation in the right testicle lasting five days. He was noted to have prostatitis and epididymitis and recommended a surgery consultation with respect to his right inguinal hernia. A June 1987 hernia evaluation ruled out a hernia. The Veteran was noted to have symptoms of right groin and testicular pain. A July 1987 in-service hospital record indicates that the Veteran underwent a circumcision and was discharged the same day. A May 1989 treatment note indicates that the Veteran complained of right groin discomfort. Presence of a hernia was ruled out following an examination. The Veteran reported vigorous sexual activity with pain lasting approximately 4 days. It was noted that his pain may be related to increased sexual activity or intermittent herniation. A May 1993 report of medical history indicates that the Veteran reported frequent or painful urination. A June 1995 report of medical history indicates that the Veteran reported frequent or painful urination. A February 1996 treatment note indicates that the Veteran had an enlarged and tender prostate and was diagnosed with possible prostatitis. A separate February 1996 treatment note indicates that the Veteran complained of frequent and painful urination for approximately a month and was treated for chlamydia. A separate February 1996 urology consultation note contains complaints of dysuria, frequent and urgent urination lasting for one month. A September 1996 separation report indicates that the Veteran reported frequent or painful urination. An October 1996 treatment note indicates that the Veteran underwent a dermatology consultation for a mole at the base of his penis. A surgical pathology report dated for the same month indicates that the Veteran's mole was removed and a biopsy revealed seborrheic keratosis. An April 2006 private treatment note from Kaiser Permanente indicates that the Veteran had a lesion on the left base of his penis which was firm and nontender. A May 2006 private treatment note from Dr. W.S.'s office contains a Peyronie's disease diagnosis. An August 2007 incomplete private treatment note from an unknown physician lists Peyronie's disease as a diagnosis. The Veteran's October 2011 Statement in Support of the Claim indicates that Peyronie's disease began in June 1987. The Veteran stated that throughout his 21 years of service, he experienced numerous urological problems that are well documented in his health records. He also stated that early signs and symptoms of his disability were overlooked by the urologist during his military carrier. A June 2016 VA Form 9 indicates that the Veteran's Peyronie's disease is a direct result of trauma to his groin and back after dicing into a swimming pool during military training. The Veteran cited August 17, 1977, June 30, 1987, and May 1, 1989 in-service treatment records. A February 2020 VA examination report indicates that the Veteran was diagnosed with Peyronie's disease in 2006. The Veteran reported sustaining an injury to the genital area in 1976 when diving into the pool and experiencing penile curvature after having a circumcision in service. The Veteran also reported a history of erectile dysfunction for several years and pain with erections intermittently. The Veteran was also noted to have a diagnosis of erectile dysfunction. Upon examination, mild leftward curvature was noted. There were no other pertinent findings. The VA examiner concluded that it is less likely than not that the Veteran's Peyronie's disease was incurred in or caused by his active service, and that the underlying pathogenesis of Peyronie's disease is unknown, but likely multifactorial with interplay between genetic predisposition, trauma, and tissue ischemia. The VA examiner stated that the record is silent for urological symptoms or trauma and cited May 1989 and April 1996 normal urological examinations. The VA examiner also stated that the Veteran's September 1996 retirement examination is silent for diagnosis of Peyronie's and that post-service medical records show a diagnosis several years after service. Pursuant to the May 2021 Board remand, the February 2020 VA medical opinion is inadequate to the extent that it did not provide an adequate rationale for the conclusion reached. Moreover, as discussed below, the opinion is contradicted by the Veteran's STRs. In August 2021, the VA produced an addendum medical opinion. The VA examiner concluded that it is less likely than not that the Veteran's Peyronie's disease was incurred in or caused by service, and that a review of the record does not indicate that the Veteran complained of, or was treated for Peyronie's disease during service. The VA examiner also noted that the only risk factor for Peyronie's that the Veteran has is trauma, noting the pool incident. It was noted that the pool incident did not result in penile trauma. The VA examiner also noted that Peyronie's disease is not due to trauma or tissue ischemia as diagnosis occurred several years after the incident. Based on the above, the evidence is at least in relative equipoise as to whether the Veteran's Peyronie's disease had its onset in service. As such, service connection is warranted. The Veteran has a current diagnosis of Peyronie's disease, as confirmed by the February 2020 VA examination report. Accordingly, the first element for establishing service connection, a current disability, has been met. STRs show that the Veteran was treated multiple times for groin pain, pain after increased sexual activity, regularly reported frequent or painful urination, and had a mole removed from the base of his penis. This includes June 1987 reports of anterior pelvic and right testicular pain, with hernia being ruled out. The evaluation specifically noted that the Veteran had these symptoms despite not being diagnosed with a hernia. Additionally, in May 1989 the Veteran complained of right groin discomfort with hernia being ruled out. It was noted that the Veteran's pain may be related to increased sexual activity. Moreover, the Veteran reported frequent or painful urination in May 1993, June 1995, February 1996, and September 1996 (discharge examination). Finally, in October 1996, the Veteran underwent a procedure of removing a mole from his penis and was diagnosed with seborrheic keratosis within one month of discharge. Thus, there are multiple injuries and reported symptoms recorded throughout the Veteran's service. While it is true that the record shows that the Veteran's in-service pool dive injury was solely to his back, the aforementioned subsequent notations illustrate multiple different injuries that occurred in service. Of note, the June 1987 hernia evaluation specifically noted that the Veteran had a painful groin and testicular pain but could not establish an etiology. This suggests that the Veteran had symptoms that remained undiagnosed. The May 1989 in-service evaluation indicated that the Veteran's pain may be related to vigorous sexual activity. Thus, the second element for establishing service connection, an in-service injury, has been satisfied. The remaining question is whether there is a nexus between the Veteran's Peyronie's disease and his service. As previously noted, here, the evidence is at least in relative equipoise as to whether the Veteran's Peyronie's disease had its onset in service. The probative medical evidence of record shows that the Veteran was seen for groin and right testicular pain of unknown etiology in service in June 1987. The evidence also shows that the same symptoms were reported in May 1989 and were attributed to vigorous sexual activity. The evidence also shows that the Veteran was treated for chlamydia in service and regularly complained of painful or frequent urination. Finally, the evidence shows that the Veteran underwent a procedure to have a growth removed from the base of his penis in October 1996. The Veteran's separation examination likewise shows that the Veteran continued to report frequent or painful urination. Additionally, at his July 2019 Board hearing, the Veteran testified that following the diving accident in service, his penis began curving to the left, and it was very painful. He also testified that the condition was embarrassing and he did not like to talk about it. Thus, in addition to the treatment he received during service as shown in the service treatment records, the Veteran also provided testimony as to his observable symptoms and the onset thereof. There is nothing in the record to suggest that the Veteran's description and onset of these symptoms is not credible. Of note, the Veteran was not diagnosed with Peyronie's until approximately 9 years after discharge. However, he reported observable symptoms of erectile dysfunction, painful erection, groin pain, and painful or frequent urination prior to his diagnosis. While the Veteran is not competent to provide a diagnosis or a nexus opinion in this case, he is competent to report observable symptoms. In this case, he reported that his symptoms had their onset in service following various injuries and treatments as noted above, continued after service, and eventually were diagnosed as Peyronie's disease in 2006. He is certainly competent to attest to these observable symptoms and there is no reason to doubt the Veteran in this regard. His statements are found to be credible, consistent, further showing that he suffered symptoms in service and after discharge. These statements are afforded probative value. By contrast, the February 2020 and August 2021 VA medical opinions could not link the Veteran's Peyronie's disease to his service. However, these VA medical opinions are not afforded probative value. The February 2020 VA medical opinion only addressed the in-service pool injury and the Veteran's circumcision, indicating that the etiology of Peyronie's disease is unknown but likely multifactorial, including genetic predisposition, trauma, and tissue ischemia. The VA examiner went on to state that the record is silent for urological symptoms or trauma. However, as noted above, the Veteran routinely reported urological symptoms during service and at discharge, was recorded to have groin pain due to sexual activity, and underwent a procedure removing a mole from his penis. Thus, the February 2020 VA medical opinion is contradicted by the record in this case. The August 2021 VA medical opinion likewise did not address any of the aforementioned in-service notations and is not afforded probative value. In sum, the evidence is at least in relative equipoise as to whether the Veteran's Peyronie's disease had its onset in service, as evidenced by recorded symptoms such as groin pain, etiology of which was unknown. The evidence consists of the Veteran's STRs containing multiple treatments and reports including a procedure during which the Veteran had a growth removed from his penis in October 1996, as well as the Veteran's reports of continuous symptoms, and private treatment records confirming a 2006 diagnosis. In other words, it is as likely as not that the Veteran's Peyronie's disease had its onset in service. This is based on the Veteran's observable symptoms of groin pain in service, urinary problems, and other treatments and trauma as described above, all of which occurred during the Veteran's lengthy 21 years of active service, and which were later attributed to the current disability. (Continued on the next page) Resolving all reasonable doubt in the Veteran's favor, his Peyronie's disease had its onset in service. Accordingly, service connection is warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kuksova, Kseniya 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.