Citation Nr: 21073369 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 18-19 306 DATE: December 8, 2021 ORDER Entitlement to service connection for hemorrhoids is denied. Entitlement to a compensable rating for anal fissures is denied. FINDINGS OF FACT 1. The probative evidence of record does not show the Veteran's hemorrhoids were related to his active-duty service or his service-connected anal fissures. 2. The Veteran's anal fissures did not manifest to constant slight, or occasional moderate leakage. CONCLUSIONS OF LAW 1. The criteria for service connection for hemorrhoids have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 2. The criteria for a compensable rating for anal fissures have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.114, Diagnostic Code 7332. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Army from February 1963 to February 1966. The Veteran died in August 2017. The Appellant is the Veteran's surviving spouse and a request for substitution was granted by the Regional Office in December 2017. In March 2020, the Appellant was provided a hearing with the undersigned Veterans Law Judge and a transcript of the proceeding is of record. The case was brought before the Board in May 2020 and was remanded for further development. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to establish service connection, the record must show competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d, 1362, 1366 (Fed. Cir. 2009). Service connection on a secondary basis essentially requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310. When considering such a claim for service connection, the Board must consider on a case-by-case basis, the competence and sufficiency of lay evidence offered to support a finding of service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau v. Nicholson, 492 F.3d 1372, 1377 Fed. Cir. 2007)). The mere conclusory or generalized lay statements that a service event or illness caused a current disability are insufficient. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Entitlement to Service Connection: Hemorrhoids The Appellant contends that the Veteran suffered from hemorrhoids that were related to his active-duty service, to include as secondary to his service-connected anal fissures. As an initial matter, the Board acknowledges that the Veteran was diagnosed with hemorrhoids. Further, the Veteran's service records show complaints of painful bowel movements and he was service-connected for anal fissures. Thus, the issue turns upon whether there is evidence of a nexus between the claimed in-service event or injury and the present disability, to include whether the condition was due to or aggravated by his service-connected anal fissures. See Sheldon v. Principi 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Board finds there is not. In July 2020, a VA opinion was obtained. The examiner opined that the Veteran's hemorrhoids were less likely than not a result of the Veteran's service-connected anal fissures or aggravated beyond their natural progression. The examiner rationalized that medical literature does not support a relationship between the occurrence of anal fissures and the development of hemorrhoids. The examiner provided that medical literature has found that complications of anal fissures include a failure to heal within 8 weeks, and recurrence and extension into the surrounding muscle. The examiner further stated that the Veteran's record cites no further occurrence of an anal fissure after 1965, and the Veteran's hemorrhoids were not diagnosed until 1998, 33 years after the anal fissure diagnosis. The examiner also noted the risk factors of hemorrhoids are known to be straining during bowel movement, sitting for long periods on the toilet, chronic diarrhea and constipation, being obese, pregnancy, anal intercourse, low fiber diet, and regular heavy lifting. The examiner stated that the Veteran's records show the Veteran did have three of the risk factors, specifically low fiber diet and heavy lifting, as his records noted the Veteran was advised to eat a high fiber diet on more than one occasion and was employed as a carpet installer. The examiner then opined that the Veteran's condition was less likely than not related to his active-duty service. The examiner rationalized that the Veteran's service treatment records do not show any occurrence of hemorrhoids up to his discharge in 1966. The examiner explained that the Veteran complained of bowel movements in March 1965 and was then diagnosed with anal fissures only. VA treatment records do show periodic complaints of hemorrhoids. However, none of the records related the Veteran's condition to his active-duty service, or his anal fissures. The Board also notes that several of his VA treatment records note the hemorrhoids in relation to the Veteran's diet-related constipation, to include his lack of fiber intake. Further, the Veteran's service treatment records are silent for any diagnosis or complaint of hemorrhoids and he reported in an April 2015 VA examination that his rectal problems did not begin until the late 1990s. Therefore, the Board finds July 2020 VA opinion to be of significant probative value in determining that the Veteran's hemorrhoids were not related to his active-duty service, or his service-connected anal fissures. The Board notes that the probative value of medical opinion evidence is based on the medical experts' personal examination of the patient, their knowledge, and skill in analyzing the data, and their medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Here, the reviewing physician's opinion was based on review of the Veteran's lay contentions, medical literature, and review of the medical evidence of record. Further, a complete and thorough rationale was provided for the opinions rendered. The Board acknowledges the Appellant's assertions that the Veteran's hemorrhoids were due to his active-duty service or his service-connected anal fissures. The Board recognizes that lay persons are competent to provide medical opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, although the Veteran and Appellant are competent to report the Veteran's symptoms, any opinion regarding whether any hemorrhoid disability is related to the Veteran's military service or to a service-connected disability requires medical expertise that the Veteran and Appellant have not demonstrated since hemorrhoid disabilities can have many causes. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (2007). Moreover, the Board again notes that the Veteran's VA treatment records consistently referred to the Veteran's hemorrhoids in relation to his lack of fiber intake and/or diet-related constipation. Further, the evidence of record shows the Veteran was not diagnosed with hemorrhoids until 1998, which is over 30 years after his active-duty service. In light of the foregoing, the Board concludes that the preponderance of the evidence is against the claim and the benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his/her ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned 38 C.F.R. § 4.7. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Additionally, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the veteran's claim is to be considered. See Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2. However, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Entitlement to a Compensable Rating: Anal Fissures The Veteran's service-connected anal fissures were provided a non-compensable rating under Diagnostic Code (DC) 7332 for Rectum and Anus, impairment of sphincter control. Under 7332, a non-compensable rating is provided for healed or slight impairment, without leakage. A 10 percent rating is provided for constant slight impairment, or occasional moderate leakage. A 30 percent is provided for occasional involuntary bowel movements, necessitating wearing a pad. A 60 percent rating is provided for extensive leakage and fairly frequent involuntary bowel movements. Lastly, a 100 percent rating is provided for complete loss of sphincter control. 38 C.F.R. § 4.114, DC 7332. In May 2015, the Veteran attended a VA examination. The examiner noted that the Veteran had impairment of rectal sphincter control with occasional slight leakage of stool on underwear which did not require an undergarment. However, on examination, although he had pink macerated skin around the anus and the gluteal fold, there was no anal fissure or external hemorrhoids. The examiner also noted that colonoscopies in March 2013 and February 2008 were both normal. Lastly, the examiner found that there was no objective evidence of an anal fissure since 1965. The examiner then opined that the Veteran's current perirectal dermatitis and anal leakage were not related to his anal fissure. In July 2020, a VA opinion was obtained. The examiner opined that the Veteran's complaints of fecal leakage and rectal bleeding were less likely than not due to his anal fissure. The examiner rationalized that there is no documentation of the Veteran having an anal fissure since 1965. The examiner explained the Veteran's symptoms more consistent with anal leakage. The examiner further noted that the Veteran's June 2015 anal manometry was normal, and he was advised to increase his fiber intake to bulk up stool. The examiner stated that at no time has the Veteran carried a diagnosis of anal fissure. VA treatment records do not show any diagnoses or mentions of the Veteran having any anal fissures, to include his multiple colonoscopies and manometry. His records further do not relate his fecal leakage symptoms to any anal fissure. In March 2017, a VA physician noted the Veteran's fecal leakage had an unclear etiology and was possibly related to weak pelvic floor muscles. The Veteran was then sent to physical therapy in May 2017, where it was noted he needed pelvic strengthening for his fecal leakage. Moreover, following his June 2016 colonoscopy, the Veteran's rectal bleeding was noted as being related to his hemorrhoids. Upon review of the evidence of record, the Board finds that a compensable rating for anal fissures is not warranted. At no time was the Veteran noted as suffering from an anal fissure. His records further do not relate his fecal leakage or bleeding to an anal fissure. In fact, VA treatment records note the Veteran's rectal bleeding as being caused by his hemorrhoids and his fecal leakage as being possibly related to weak pelvic floor muscles. He was further consistently noted as needing to up his fiber intake to stop the fecal leakage. Therefore, although the Veteran did have leakage symptoms, the evidence of record does not show that his symptoms were due to his service-connected anal fissures. The Board acknowledges the Appellant's assertions that the Veteran's anal fissures warrant a compensable rating. The Board recognizes that lay persons are competent to provide medical opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, although the Veteran and Appellant are competent to report his symptoms, any opinion regarding whether the symptoms were part of a service-connected disability requires medical expertise that the Veteran and Appellant have not demonstrated. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (2007). The Board acknowledges the Appellant's statements and the Veteran's previous statements that his anal fissure warrants a compensable rating. The Board recognizes that the Veteran was competent to report his symptoms, such as rectal bleeding and leakage. See Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, while the Board empathizes with the Appellant's statements that the Veteran suffered from severe fecal leakage and bleeding, the evidence of record does not show that the Veteran's symptoms were related to anal fissures nor that the Veteran suffered from anal fissures at any time during the pendency of the appeal. Thus, the Board has determined that the evidence of record is consistent with the rating assigned. In light of the foregoing, the Board concludes that the preponderance of evidence is against the claim and the benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed Cir. 2001). JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Negron, 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.