Citation Nr: 21072508 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 15-14 739 DATE: December 3, 2021 ORDER Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected hypertension, is denied. FINDING OF FACT The Veteran's erectile dysfunction did not originate in service or until years after service and is not otherwise etiologically related to service or to a service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection for erectile dysfunction, to include as secondary to the Veteran's service-connected hypertension, have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1972 to February 1973, May 1973 to June 1976, and September 1977 to April 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2019, the Veteran and his wife testified at a videoconference with the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is of record. This case was last before the Board in August 2021 and remanded for additional development. The case is now again before the Board for further appellate action. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Service connection may be granted on a secondary basis where the evidence shows (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The benefit of the doubt rule provides that a veteran will prevail in a case where the positive evidence is in a relative balance with the negative evidence. Therefore, the Veteran prevails in a claim when: (1) the weight of the evidence supports the claim, or (2) when the evidence is in equipoise. It is only when the weight of the evidence is against the claim that the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for erectile dysfunction, to include as secondary to service-connected hypertension, is denied. The Veteran contends that he has erectile dysfunction that is related to an in-service, event, illness, or injury, including as secondary to his service-connected hypertension. The Veteran contends that he had testicle pain and swelling during his active service. A review of the Veteran's service medical records does not reflect any complaints, findings, or treatment for any conditions related to erectile dysfunction. A March 1994 service medical examination did not include any complaints of erectile dysfunction. The Veteran was discharged from Active service on April 30, 1996. An October 1996 treatment record reported the Veteran had experienced testicular pain for one month. The assessment was testicular swelling. An October 1996 private medical record reported the Veteran had mild testicular pain with heavy work and exercise. He had a small right "supratesticular" mass that most probably represents an early spermatocele or an epididymal cyst. A November 8, 1996 medical treatment entry reported the Veteran complained of right testicular enlargement with occasional pain. He denied penile "o/c" or problems with ejaculation. He also complained of occasional urinary frequency and hesitancy. The provisional diagnosis was rule/out testicular cancer, chronic prostatitis, and chronic epididymitis. A November 1996 treatment record reported that the Veteran denied a history of hypertension but had been found to have elevated blood pressure on two successive clinic visits. A November 15, 1996 treatment record reported the Veteran experienced intermittent inguinal/testicular pain and enlargement. The Veteran noted the size of his right testes had been enlarged since age 16. He was diagnosed with right hydrocele. A November 22, 1996 medical treatment entry indicates the Veteran had a lifelong history of his right testes being larger than his left. He also complained of increased urinary frequency and pain for the past 3 to 4 months. His main concern was post void dribbling. A December 1996 testicular ultrasound resulted in an impression of bilateral hydroceles with no testicular mass. A July 2004 primary care note indicates the Veteran was prescribed Sildenafil (Viagra) on June 7, 2004. A February 2005 medical record lists male erectile disorder as one of the Veteran's listed medical problems. A May 2005 medical record reported that the Veteran was referred for a report of hydrocele. The Veteran complained of localized point tenderness position to right testes coinciding to an enlarging nodule. The Veteran noted it was getting slightly larger over past several years. He was diagnosed with right spermatocele and benign prostatic hypertrophy/lower urinary tract symptoms. A March 2007 treatment record reported the Veteran had decreased libido and performance. He was diagnosed with male erectile disorder. A September 2008 treatment record reports that the Veteran complained of erection problems and asked for medication. He was diagnosed with male erectile disorder. The Veteran was provided a VA examination for male reproductive organ conditions in May 2021. The Veteran reported the onset was 1996-1997. He recalled losing endurance and tumescence of erections. According to the Veteran, in 2001, he sought care and was prescribed Viagra. The examiner diagnosed the Veteran with erectile dysfunction. The examiner opined that the Veteran's erectile dysfunction is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected hypertension, including any medications used to treat hypertension. As rationale, the examiner explained that, while hypertension can exert a negative effect on erectile performance, the Veteran's timeline and medical profile does not support any positive connection between the Veteran developing hypertension prior to developing erectile dysfunction. The Veteran's records show that he developed diabetes mellitus at the same time of hypertension. Diabetes would be just as likely, if not more likely, than hypertension to cause erectile dysfunction. Regardless, the three conditions developed at the same time, and it is not possible to determine any sequence of which developed first and/or any causal connection. The examiner explained that the medications for hypertension actually have a proven track record of improving blood flow and, thus, erectile health. This includes Valsartan, Losartan, and Entresto. The Veteran reported being on Spironolactone; however, this is due to his congestive heart failure and not hypertension. The examiner stated that Spironolactone actually also helps with erectile dysfunction. Erectile dysfunction is a common condition for even males with no concomitant co-morbidities; however, the Veteran has both diabetes and hypertension, along with hyperlipidemia. All three of these conditions can affect erectile dysfunction. However, the Veteran's current records do not show any timeline or literature-backed connection between any medication and the onset of erectile dysfunction. The examiner also opined that the Veteran's erectile dysfunction was less likely than not aggravated beyond its natural progression by the Veteran's service-connected hypertension, including any medications used to treat hypertension. As rationale, the examiner explained that there is no indication of any worsening of erectile dysfunction. The examiner stated that worsening cannot be accurately measured or objectively assessed with regard to endothelial or neural impact. The Veteran's records show his erectile dysfunction started in or around 2005 and was treated with Viagra. The Viagra caused headaches, so he was switched to another drug that worked on a different mechanism. There is no evidence that any medication made this worse. Lastly, the Veteran has developed congestive heart failure. If there was any reason or cause for worsening, it would be due to the congestive heart failure and not to hypertension and/or his medications for hypertension. The Veteran was provided another VA medical opinion regarding his erectile dysfunction in September 2021. The examiner opined that the Veteran's erectile dysfunction was less likely than not (less than 50 percent probability) incurred in or caused by an in-service illness, event, or injury. As rationale, the examiner explained that the Veteran's records first note erectile dysfunction in 2004. At the time, the Veteran was 52 years old, which is in a normal age range for men developing problems with sexual performance. The examiner reported that the Veteran's records show evidence of a couple of complaints that might be related by proximity and/or anatomy. An October 1996 record reports complaints of a right, painful, testicular mass. This was equated to a potential spermatocele or epidydimal cyst. However, neither of these conditions would lead to erectile dysfunction and both are transient or self-limiting. The notes also show that the pain was specific to exercise or work. His records also show a change in urination that appears to have been related to a developing benign prostatic hypertrophy. Current medical literature does not show any pathological influence of benign prostatic hypertrophy to developing erectile dysfunction. The Veteran's records show that he more likely developed erectile dysfunction shortly after retiring, and then sought care. A review of the Veteran's service medical records does not reflect any complaints, findings, or treatment for any conditions related to erectile dysfunction. A March 1994 service medical examination did not include any complaints of erectile dysfunction. In October 1996, approximately six months after discharge, the Veteran complained of experiencing testicular pain for one month. A July 2004 primary care note indicates the Veteran was prescribed Sildenafil (Viagra), a medication used to treat erectile dysfunction, on June 7, 2004, which was more than eight years after the Veteran's discharge from active service. Although a lay person is competent to address etiology in some limited circumstances in which nexus is obvious merely through lay observation, the question of causation for the Veteran's erectile dysfunction extends beyond an immediately observable cause-and-effect relationship. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the Veteran is not competent to address the etiology of his erectile dysfunction. Consequently, the Board gives more probative weight to the May 2021 and September 2021 medical opinions. After reviewing the Veteran's claims file and examining the Veteran, the May 2021 examiner opined that the Veteran's erectile dysfunction is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected hypertension, including any medications used to treat hypertension, as the Veteran's records do not show any timeline or literature-backed connection between any medication and the onset of erectile dysfunction. The May 2021 examiner also opined that the Veteran's erectile dysfunction was less likely than not aggravated beyond its natural progression by the Veteran's service-connected hypertension, including any medications used to treat hypertension. As rationale, the examiner explained that there is no indication of any worsening of erectile dysfunction and no evidence that any medication made the condition worse. After reviewing the Veteran's record, the September 2021 examiner opined that the Veteran's erectile dysfunction was less likely than not incurred in or caused by an in-service illness, event, or injury. The examiner explained that the Veteran's records first note erectile dysfunction in 2004 when the Veteran was 52 years old, which is within a normal age range for men developing problems with sexual performance. The examiner explained that the conditions in 1996 would not lead to erectile dysfunction. Based on a review of the foregoing evidence and the applicable laws and regulations, the Board finds that the preponderance of the evidence is against the Veteran's service connection claim for erectile dysfunction. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, that doctrine is not helpful to this claimant. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Service connection has not been established and the Veteran's claim for erectile dysfunction must be denied. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Moore, 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.