Citation Nr: 21072793 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 15-36 784 DATE: December 6, 2021 REMANDED Issue of entitlement to an initial compensable rating for erectile dysfunction with low testosterone is remanded. Issue of entitlement to an initial compensable rating for varicocele is remanded. Issue of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 2000 to November 2002. This appeal to the Board of Veterans' Appeals (Board) arose from an October 2016 rating decision issued by the Department of Veterans Affairs (VA). See November 2016 Notice of Disagreement (NOD); December 2016 Statement of the Case (SOC); January 2017 Substantive Appeal (VA Form 9). The Veteran testified before the undersigned Veterans Law Judge in a December 2018 hearing. See December 2018 Hearing transcript. In April 2019, the Board remanded the claims to provide the Veteran the opportunity for more recent VA examinations due to his complaint of worsening symptoms. April 2019 Board Decision. In April 2020, the Board remanded the claims again for further development, specifically for whether the Veteran's reported urinary dysfunction is a symptom associated with his erectile dysfunction or varicocele. April 2020 Board Decision. The agency of original jurisdiction (AOJ) developed the evidence and continued the denial of the above claims. See August 2021 Supplemental Statement of the Case. The Board notes that the issues of entitlement to service connection for sciatica of the right and left lower extremity, lower lumbar spine injury, hearing loss, tinnitus, residuals of a congenital left and right club foot status post transmetatarsal amputation, degenerative joint disease of the left and right ankle, and right knee patella tendonitis were also discussed during April 2019 Board hearing. The issues of entitlement to compensation under provision 38 U.S.C. § 1151 for amputation of his toes and entitlement to a compensable rating for his residuals of left fifth finger fingertip amputation were also discussed. Id. During the pendency of the appeal, the Veteran's claims of entitlement to service connection for sciatica of the right and left lower extremity, lower lumbar spine injury, residuals of a congenital left and right club foot status post transmetatarsal amputation, degenerative joint disease of the left and right ankle, and right knee patella tendonitis were granted by the AOJ. See June 2020 Rating decision; November 2020 Rating Decision; April 2021 Rating Decision; August 2021 Rating Decision. This is considered a full grant of the benefits sought for those issues. As for the Veteran's claims of entitlement to service connection for hearing loss and tinnitus, and to compensation under provision 38 U.S.C. § 1151 for amputation of his toes, those claims were denied in the April 2019 Board Decision and not further appealed; although the Veteran's claim of entitlement to service connection for tinnitus was later granted by the AOJ in a subsequent claim. See April 2019 Board Decision; February 2020 Court of Appeals for Veterans Claims Decision; June 2020 Rating Decision. Finally, the Veteran's claim of entitlement to a compensable rating for residuals of left fifth finger fingertip amputation was denied in the June 2021 Board decision. These claims are, thus, currently no longer in appellate status and before the Board. 1. Issue of entitlement to an initial compensable rating for erectile dysfunction with low testosterone is remanded. 2. Issue of entitlement to an initial compensable rating for varicocele is remanded. Unfortunately, the Board finds that another remand is required for the issues of entitlement to initial compensable ratings for erectile dysfunction with low testosterone and varicocele. The June 2021 Board decision remanded the claims and directed that an opinion from a VA examiner be obtained to address whether the Veteran's erectile dysfunction with low testosterone or varicocele was associated with his reported urinary leakage. The Board also directed that the opinion specifically address the UpToDate article titled "Lower urinary tract symptoms in males" cited by the December 2020 VA examiner. Id. The Board decision noted that the December 2020 VA examiner opined that the article supports no plausible secondary relationship between erectile dysfunction or varicocele and lower urinary tract symptoms, but the Board's review of the article showed it lists erectile dysfunction among a list of conditions associated with lower urinary tract symptoms. Id. The Board also directed that a more detailed explanation as to why the Veteran's voiding dysfunction etiology is "unknown" is needed, including whether additional evidence such as relevant testing or a specialist opinion could identify the cause, or if the etiology is beyond the limits of medical knowledge. Id. Two VA examiners' opinions were obtained on remand. The July 2021 VA examiner opined that the Veteran's urinary dysfunction is not associated with his erectile dysfunction or varicocele based on the medical literature, but provided no specific citation and did not discuss the UpToDate article as directed by the Board. See July 2021 VA Examination Medical Opinion. The September 2021 VA examiner opined that the exact cause of the Veteran's reported urinary dysfunction is unknown without objective evidence, but provides no further detail as to what evidence or testing would be needed. September 2021 VA Examination Medical Opinion. The Board finds that the VA examiners' opinions do not fully comply with its June 2021 remand directives. In addition, the July 2021 VA examiner opined that the Veteran's varicocele has resolved per a May 2015 treatment record showing no objective evidence of recurrent varicocele following orchidopexy, but the September 2021 VA examiner opined that an examination would be needed to make a determination. July 2021 VA Examination Medical Opinion; September 2021 VA Examination Medical Opinion. Clarification as to if the evidence supports the Veteran's varicocele improved or resolved is needed. The Board, thus, finds that the Veteran should be afforded another opportunity for a VA examination. 3. Issue of entitlement to a TDIU is remanded. As a decision on whether the Veteran's urinary dyfunction issues are due to his service-connected erectile dysfunction or varicocele could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. In addition, the Veteran testified during the December 2018 Board hearing that he sees clients/patients as part of his clinical social work. December 2018 Hearing Transcript. The only VA Form 21-8940 was submitted in April 2013 and contains no employment information. The Board finds that an attempt to update the Veteran's work history is needed. The matters are REMANDED for the following action: 1. Develop the evidence necessary deemed necessary by the AOJ to adjudicate the Veteran's claim of entitlement to a TDIU, to include requesting that the Veteran complete a VA Form 21 8940 with his employment history. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the severity of his service-connected erectile dysfunction with low testosterone and varicocele since his May 2016 claim to present. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. (a) The examiner should address whether the evidence supports that the Veteran's varicocele has improved or resolved. The examiner should discuss the July 2021 VA examiner's finding that a May 2015 treatment record shows the Veteran's varicocele as resolved and the September 2021 VA examiner's opinion that an examination is needed to make that determination. (b) The VA examiner should also specifically consider and discuss the Veteran's report of having urinary leakage since 2012 and opine on whether that urinary leakage is at least as likely as not a symptom of his erectile dysfunction with low testosterone and/or varicocele. The Board notes that, for the purposes of obtaining this opinion, the examiner should presume that the Veteran's statements about having urinary leakage beginning in 2012 to be true. However, if there is any medical reason to accept or reject the Veteran's reported urinary leakage symptoms, this should be noted. (Continued on the next page) The examiner should specifically consider and discuss the article cited by the December 2020 VA examiner and titled "Lower Urinary Tract Symptoms in Men." Does the article, under "prevalence and risk factors" section, list erectile dysfunction as a condition associated with lower urinary tract symptoms? If so, how does this factor into whether the Veteran's urinary leakage is a symptom of his erectile dysfunction? R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Lin 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.