Citation Nr: 21073417 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 15-06 603 DATE: December 8, 2021 ORDER Restoration of a 30 percent disability rating for service-connected prostate cancer residuals manifested by radiation colitis is granted, effective August 14, 2012. Entitlement to a rating in excess of 30 percent for service-connected prostate cancer residuals manifested by radiation colitis is denied. Entitlement to a separate 20 percent disability rating for service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction with erectile dysfunction is granted, effective November 27, 2009. Entitlement to a 40 percent disability rating for service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction with erectile dysfunction is granted, effective November 20, 2017. Entitlement to a rating in excess of 20 percent prior to November 20, 2017, and in excess of 40 percent thereafter, for service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is granted, effective November 27, 2009. FINDINGS OF FACT 1. The Veteran's 30 percent disability rating under Diagnostic Code 7323, which includes radiation colitis as a residual of prostate cancer, was in place from January 1, 2006 to August 14, 2012. 2. In changing the Veteran's 30 percent disability rating under Diagnostic Code 7323 for radiation colitis into a separate 20 percent disability rating for urinary frequency under Diagnostic Code 7528 and a 10 percent disability rating for radiation colitis under Diagnostic Code 7319, the agency of original jurisdiction (AOJ) effectively reduced the rating assigned to the Veteran's radiation colitis to 10 percent, as Diagnostic Code 7528 and Diagnostic Code 7319 compensate distinct and separate manifestations of his prostate cancer. 3. At no time during the appeal period has the Veteran's service-connected prostate cancer residuals manifested by radiation colitis been shown to be severe with numerous attacks a year and malnutrition, with health only fair during remission; or pronounced resulting in marked malnutrition, anemia, and general disability or with serious complication such as liver abscess. 4. Prior to November 2017, the Veteran's service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction was shown to cause a daytime voiding interval between one and two hours, and/or awakening three or four times per night to urinate; however, it was not manifested by a voiding interval of less than one hour, awakening five times or more per night to urinate, requiring the use of wearing absorbent materials which must be changed two or more times per day and/or it did not require the use of an appliance. 5. From November 2017, the Veteran's prostate cancer residuals manifested by urinary frequency and voiding dysfunction requiring the use of absorbent materials which must be changed two to four times per day, but no more, and it did not require the use of an appliance. 6. Resolving all reasonable doubt in the Veteran's favor, he was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities from November 27, 2009. CONCLUSIONS OF LAW 1. The 30 percent disability rating under Diagnostic Code 7323 for radiation colitis as a residual of prostate cancer is restored, effective August 14, 2012. 38 U.S.C. § 110; 38 C.F.R. §§ 3.105, 3.344. 2. The criteria for a disability rating in excess of 30 percent for radiation colitis as a residual of prostate cancer are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7323. 3. The criteria for 20 percent disability rating for service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction are met, effective November 27, 2009. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.115a. 4. The criteria for a 40 percent disability rating for service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction are met, effective November 2017. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.115a. 5. The criteria for a disability rating in excess of 20 percent prior to November 2017, and in excess of 40 percent thereafter for service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.115a. 6. The criteria for an award of a TDIU are met from November 27, 2009. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1969 to December 1970, to include service in the Republic of Vietnam. I. INCREASED RATINGS Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. By way of background, a July 2003 rating decision awarded service connection for the Veteran's prostate cancer and assigned an initial 100 percent disability rating under Diagnostic Code 5257, effective March 27, 2003, the day after the Veteran was discharged from active duty. In an October 2005 rating decision, the AOJ reduced disability rating assigned to the Veteran's service-connected prostate cancer from 100 percent to 30 percent, effective January 1, 2006. Although the 30 percent rating was assigned under Diagnostic Code 7528, the AOJ indicated that the rating was assigned for the residual of radiation colitis and erectile dysfunction. In reviewing the rating decision, it is clear that his radiation colitis was rated by analogy using Diagnostic Code 7323, which pertains to ulcerative colitis, and he was assigned a 30 percent disability rating for moderately-severe colitis with frequent exacerbations. In the April 2010 rating decision on appeal, the AOJ denied a rating in excess of 30 percent for the Veteran's service-connected prostate cancer with residuals of radiation colitis and erectile dysfunction. Thereafter, based upon the results contained in an August 2012 VA examination report, the AOJ issued a rating decision in January 2015 separating the Veteran's 30 percent disability rating into two separate ratings for two separate and distinct residuals. First, the AOJ noted that it was assigning a 20 percent disability rating for prostate cancer residuals manifested by urinary frequency and erectile dysfunction, effective August 14, 2012. Then, the AOJ assigned a 10 percent disability rating for prostate cancer residuals manifested by radiation colitis, bowel dysfunction, effective August 12, 2012. In doing so, the AOJ assigned Diagnostic Code 7528 to the Veteran's residuals manifested by urinary frequency and erectile dysfunction, and it assigned Diagnostic Code 7319 to his prostate cancer residuals manifested by radiation colitis, bowel dysfunction. See 38 C.F.R. § 4.114, 4.115a, 4.115b. At the outset, the Board finds that the 30 percent disability rating previously assigned to the Veteran's residual of radiation colitis under Diagnostic Code 7323 must be restored. While changing a Diagnostic Code is certainly permissible, such cannot result in a change in the essence of the assessed disability. See Murray v. Shinseki, 24 Vet. App. 420 (2011). If a disability is service-connected and rated for particular manifestations, the basis of that rating cannot change without due process. See 38 C.F.R. §§ 3.105, 3.344. As noted above, his residual of radiation colitis was assigned a 30 percent disability rating under Diagnostic Code 7323 for moderately-severe colitis with frequent exacerbations. By separating out the Veteran's residuals and assigning two separate ratings (20 percent for urinary frequency and 10 percent for radiation colitis), the January 2015 rating decision amounted to a reduction from 30 percent to 10 percent for his radiation colitis without affording the Veteran due process, as radiation colitis and urinary frequency are distinct and separate residuals of the Veteran's prostate cancer. See Murray, supra; see also Esteban, 6 Vet. App. at 261-62. While changing a diagnostic code is certainly permissible, the Court has held that if a veteran's symptoms are distinct and separate, the veteran is entitled to separate disability ratings for the various conditions. See Murray, supra. Accordingly, the 30 percent disability rating under Diagnostic Code 7323 is restored, effective August 14, 2012, the effective date of its erroneous reduction. Under Diagnostic Code 7319, which pertains to irritable colon syndrome, a 30 percent disability rating is assigned for severe symptomatology manifested by diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114. The 30 percent disability rating is the maximum schedular disability rating available under Diagnostic Code 7319. Id. Diagnostic Code 7323 applies to digestive conditions diagnosed as ulcerative colitis and provides as follows: a 30 percent rating is warranted for moderately severe symptoms with frequent exacerbations; a 60 percent rating is warranted for severe symptoms with numerous attacks a year and malnutrition, with health only fair during remissions; and a 100 percent rating is warranted for pronounced symptoms resulting in marked malnutrition, anemia, and general debility, or with serious complications, such as liver abscess. See 38 C.F.R. § 4.114, Diagnostic Code 7323. The words slight, moderate, and severe as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities; thus, rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. See 38 C.F.R. § 4.6. Moreover, use of terminology such as severe by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue as all evidence must be evaluated in connection with the adjudication of an increased rating claim. See 38 C.F.R. §§ 4.2, 4.6. For purposes of evaluating gastrointestinal conditions under Section 4.114, the term "substantial weight loss" means a loss of greater than 20 percent of the individual's baseline weight, sustained for three months or longer; and the term "minor weight loss" means a weight loss of 10 to 20 percent of the individual's baseline weight, sustained for three months or longer. The term "inability to gain weight" means that there has been substantial weight loss with inability to regain it despite appropriate therapy. "Baseline weight" means the average weight for the two-year-period preceding onset of the disease. See 38 C.F.R. § 4.112. Certain diseases of the digestive system, particularly within the abdomen, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia, and disturbances in nutrition. Consequently, certain coexisting diseases in this area, as indicated in the instruction under the title "Diseases of the Digestive System," do not lend themselves to distinct and separate disability evaluations without violating the fundamental principle relating to pyramiding, which must be avoided. See 38 C.F.R. §§ 4.14, 4.113. In addition, certain diseases of the digestive system, corresponding to Diagnostic Codes 7301 to 7329, 7331, 7342, and 7345 to 7348, may not be combined with each other; rather a single rating must be assigned under the diagnostic code indicating the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability so warrants. See 38 C.F.R. § 4.114. Under 38 C.F.R. § 4.115a, any voiding dysfunction shall be rated by the particular condition as urine leakage, urinary frequency, or obstructive voiding. With respect to urine leakage (continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence), a 60 percent disability rating is warranted for the use of an appliance or the wearing of absorbent materials which must be changed more than four times per day. A 40 percent disability rating is warranted for the wearing of absorbent materials which must be changed two to four times per day. A 20 percent disability rating is warranted for the wearing of absorbent materials which must be changed less than two times per day. 38 C.F.R. § 4.115a. With respect to urinary frequency, a 40 percent disability rating is warranted for a daytime voiding interval of less than one hour or awakening to void five or more times per night. A 20 percent disability rating is warranted for a daytime voiding interval between one and two hours or awakening to void three to four times per night. A 10 percent disability rating is warranted for a daytime voiding interval between two and three hours or awakening to void two times per night. Id. Pertinent evidence of record includes VA examination reports, the Veteran's VA treatment records, his private treatment records, and the lay statements of record, including the testimony provided by the Veteran and his wife before the undersigned Veterans Law Judge in August 2018. In a December 2009 statement, the Veteran reported bowel leakages if he was unable to get to a bathroom in time. He also reported urinary frequency, including having to get up during the night which prevented him from getting a full night's rest. In January 2010, the Veteran underwent a VA examination, and he reported urinating eight to nine times per day and two to three times per night. The Veteran also reported a weak stream, but he denied dysuria. He denied incontinence, but he reported recurrent urinary tract infections, as well as a history of renal clinic and bladder stones with acute nephritis. The Veteran also denied any trauma or surgery associated with his penis or testicles, but he was unable to achieve an erection on his own. The Veteran denied any functional limitation in his ability to care for his own activities of daily living. He stated that he was working part time as a teacher, but he denied any loss from work in the prior year. An October 2011 VA treatment record noted that the Veteran had a colonoscopy in May showing some residual colitis from radiation from his prostate cancer, and that he had diarrhea on a fairly frequent basis. In August 2012, the Veteran underwent another VA examination, and the examiner noted his reports of voiding dysfunction, erectile dysfunction, and bowel dysfunction. As for his bowel dysfunction, he reported bowel urgency with diarrhea, as well as occasional bowel accidents when he was unable to make it to the restroom in time. He denied wearing pads. As for the voiding dysfunction, the Veteran denied the use of an appliance, but he reported a daytime voiding interval between one and two hours, as well as having to wake up two times during the night. The examiner also noted his erectile dysfunction, and that he was unable to achieve an erection sufficient for penetration and ejaculation without medication. With specific regard to the Veteran's colitis, the examiner noted that the Veteran's symptoms included bowel urgency with diarrhea and occasional bowel accidents when he was unable to make it to the restroom in time. The examiner noted the continuous mediation was required to control his condition; nevertheless, he experienced diarrhea three to four times a day every three days. The examiner noted that the Veteran did not have episodes of bowel disturbance with abdominal distress or exacerbations or attacks of an intestinal condition; and he did not have malnutrition, serious complications, or other general health effects attributable to his intestinal condition. As for the functional impairment associated with his disability, the examiner noted that his frequent bowel movements interfered with his ability work. An April 2017 private treatment record noted that the Veteran experienced urinary incontinence due to urgency that caused leakage if he was unable to get to the bathroom immediately. A November 2017 VA treatment record noted that urinary pads were recommended for the Veteran. Subsequent VA treatment records indicate that he changed them three times per day. In an April 2018 statement, the Veteran stated that he developed a loss of urine control and bowel issues as a result of his treatment for prostate cancer. He stated that he changed his underwear two or three times a day, and he had been issued absorbent pads by the VA. He stated that he stopped teaching in 2004. He indicated that he stayed close to a restroom at all times, but he still experienced involuntary bowel leakage. In an April 2018 statement, the Veteran's wife noted that traveling in a vehicle was hard for the Veteran due to his frequent urination, and that he had trouble with urine leakage. Also, she noted that he experienced bowel leakage requiring a guard at all times. A June 2018 private treatment record noted that the Veteran had a normotensive sphincter at rest but slightly hypotensive with squeeze, indicating a partial defect in the sphincter muscle. A July 2018 private treatment record noted the Veteran's problems with erectile dysfunction, as well as urinary incontinence, requiring three to four pads a day. He also reported abnormal sensation when he needed to urinate, as well as having to strain or bear down to start his urinary stream. As for his incontinence, it was noted that he would leak if he was not able to get to a bathroom in time, and he described the leakage as severe. The treatment provider noted that, more than fifty percent of the time, he needed to urinate fewer than two hours after he finished urinating. Also, the treatment provider noted that he had to get up to urinate four times a night. The Veteran's treatment provider then noted that his use of multiple pads throughout the day greatly limited his ability to carry out many of his regular daily activities, such as working for any period of time and not having immediate access to the bathroom or the ability to change his clothes immediately. A July 2018 letter from the Veteran's treatment provider noted that he was troubled by fecal incontinence due, in part, to a partial defect in the sphincter muscles. It was noted that the problems results in his inability to control his loss of stool. This problem, in turn, was very disabling for any occupational or social situation. In August 2018, the Veteran testified before the undersigned Veterans Law Judge, and he reported using absorbent material due to leakage, and having to change them four times a day. He also reported frequent urinary infections which required medication, as well as a daytime voiding interval of less than one hour and a nighttime voiding interval of four times per night on his worst nights. He also reported a consistent problem with erectile dysfunction, noting that medication was no longer working. The Veteran reported alternating instances of constipation and frequent diarrhea, along with abdominal distress and pain. He then testified that he had to stop teaching as a result of the functional impairment associated with his disabilities. He also testified that he was working part-time at a local church as a minister. The Veteran then testified that he experienced both urinary leakage and fecal leakage, which began more recently. In a February 2019 statement, the Veteran reported that his urinary frequency had increased, noting that he needed to use three to four pads per day due to his loss of bladder control. The Veteran underwent more examinations in September 2019, and the examiner noted that the problems associated with his service-connected prostate cancer included urinary issues, bowel issues, and erectile dysfunction. He reported that he was unable to work due to his urinary and bowel problems. The examiner the noted that the Veteran's experienced voiding dysfunction causing urine leakage that required absorbent material that must be changed two to four times per day. As for his urinary frequency, the examiner noted that the voiding interval was between two and three hours, and that he had to wake twice during the night. As for the functional impairment associated with the Veteran's disability and the impact that his disability had on his ability work, the examiner noted that he needed to be near a bathroom for frequency toileting. Regarding the Veteran's radiation colitis, the examiner noted that the condition started when he started to experienced bowel movement without control. The examiner also noted that the condition was embarrassing, causing him to be a rush in public, and the Veteran had to quit teaching due to his condition. The examiner noted that continuous medication was not required, and that he had not had surgery. The examiner then indicated that the Veteran did not have episodes of bowel disturbance with abdominal distress or exacerbations, that he did not have weight loss attributable to an intestinal condition, and that he did not have malnutrition, serious complications, or other general health effects attributable to his intestinal condition. It was then noted that the Veteran's radiation colitis required wearing disposable briefs and frequent toileting. The Veteran underwent more examinations in February 2020, and the examiner noted that the problems associated with his service-connected prostate cancer included painful bowel movements, residual erectile dysfunction, and incontinence of the bladder and bowel. The examiner the noted that the Veteran's experienced voiding dysfunction causing urine leakage that required absorbent material that must be changed two to four times per day. As for the Veteran's urinary frequency, the examiner noted that the voiding interval was between one and two hours, and that he had to wake three to four times during the night. Regarding the Veteran's radiation colitis, the examiner noted that the condition started when he started to experienced bowel movement without control. The examiner also noted that the condition involved painful bowel movements as well as discoordinated bowel movements at times. The examiner noted that continuous medication was not required, but his symptoms include trouble initiating bowel movements and urgency. The examiner then indicated that the Veteran had episodes of bowel disturbance with abdominal distress on a more or less constant basis. However, he did not have weight loss attributable to an intestinal condition, and he did not experience malnutrition, serious complications, or other general health effects attributable to his intestinal condition. It was then noted that the Veteran was unable to be too far from a bathroom, and that he could not perform any occupation requiring remote work or work away from a restroom. Based on the evidence of record, and after resolving all reasonable doubt in the Veteran's favor, the Board finds that a separate 20 percent disability rating is warranted for his service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction with erectile dysfunction. Indeed, beginning with his January 2010 VA examination, he has consistently reported a daytime voiding interval one and two hours, as well as waking up approximately three times per night to urinate. The Veteran's lay statements were subsequently confirmed during the August 2012 VA examination, when the examiner noted that his daytime voiding interval was between one and two hours. As such, the Board finds that a separate 20 percent disability rating is warranted for the Veteran's service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction with erectile dysfunction is granted, effective November 27, 2009, the day his claim for an increased rating was received. Furthermore, based on the evidence of record, and after resolving all reasonable doubt in the Veteran's favor, the Board finds that an increased disability rating of 40 percent is warranted for his service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction with erectile dysfunction, effective November 20, 2017. Indeed, as noted above, a November 2017 VA treatment record noted that urinary pads were recommended for the Veteran due to his voiding dysfunction, and subsequent VA treatment records indicate that he changed them three times per day. Furthermore, the frequency with which he changed his absorbent pads was subsequently confirmed by the Veteran's private treatment records, the VA examination reports, and his testimony before the undersigned Veterans Law Judge. However, the Board finds that higher ratings are not warranted at any other time for the Veteran's prostate cancer residuals, including his radiation colitis, urinary frequency and voiding dysfunction, and his erectile dysfunction. First, with regard to his radiation colitis, a rating higher than 30 percent is not available under Diagnostic Code 7319. As for Diagnostic Code 7323, under which the Veteran is currently rated, a higher rating is not warranted unless the colitis is severe with numerous attacks a year and malnutrition, with health only fair during remission; or pronounced resulting in marked malnutrition, anemia, and general disability or with serious complication such as liver abscess. However, as noted above, the August 2012, September 2019, and February 2020 examination reports each indicated that the Veteran's radiation colitis did not involve malnutrition, serious complications, or other general health effects attributable to his intestinal condition. As such, a rating in excess of 30 percent for the Veteran's service-connected prostate cancer residuals manifested by radiation colitis is not warranted at any point during the appeal period. As for the Veteran's urinary frequency and voiding dysfunction, the Board finds that a rating in excess of 20 percent prior to November 20, 2017, and in excess of 40 percent thereafter, is not warranted at any point during the appeal period. As for voiding dysfunction prior to November 20, 2017, there was nothing in the claims file suggesting that the Veteran used an appliance or wore absorbent material to manage his symptoms. Furthermore, the evidence of record, to specifically include his lay statements, indicated that his urinary frequency was manifested by no more than a daytime voiding interval between one and two hours, and/or awakening three or four times per night to urinate. As such, a rating in excess of 20 percent prior to November 20, 2017, for the Veteran's service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction is not warranted. From November 20, 2017, there was nothing in the claims file suggesting that Veteran's prostate cancer residuals manifested by urinary frequency and voiding dysfunction required the use of an appliance or that it required changing his absorbent pads more than four times per day. Indeed, an addition to the VA examination reports and treatment record, the Veteran testified that he changed his absorbent pads due to urinary leakage four times a day on his worst days. See August 2018 Hearing Transcript, pp. 3-4. As such, a rating in excess of 40 percent from November 20, 2017, for the Veteran's service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction is not warranted. As for the Veteran's erectile dysfunction, the Board notes that a July 2005 rating decision awarded Special Monthly Compensation (SMC) under 38 U.S.C. § 1114(k) and 38 C.F.R. § 3.350(a) due to loss of use of a creative organ, effective May 31, 2005. Under Diagnostic Code 7522, a 20 percent rating is warranted for deformity of the penis with loss of erectile power. See 38 C.F.R. § 4.115b. Based on the evidence of record, the Board finds that the Veteran's erectile dysfunction does not warrant a separate compensable rating at any time pertinent to the appeal. Specifically, the evidence of record fails to demonstrate a penile deformity at any time pertinent to the current appeal, as the Veteran's private and VA treatment records do not indicate any penis deformity. As the evidence does not show that the Veteran has a penis deformity in addition to the sexual dysfunction, a compensable evaluation is not warranted. See 38 C.F.R. § 4.115b, Diagnostic Code 7522. As noted above, however, the Veteran has been awarded SMC for loss of use of a creative organ, since the May 31, 2005. In assessing the severity of the residuals associated with the Veteran's service connected prostate cancer, the Board has considered his assertions regarding his symptoms, which he is certainly competent to provide. See Layno v. Brown, 6 Vet. App. 465 (1994); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Indeed, in assigning the 20 percent rating effective November 27, 2009, and the 40 percent rating, effective November 20, 2017, for urinary frequency and voiding dysfunction, the Board has relied in large part on the lay statements of record, coupled with the specialized medical determinations pertinent the identified residuals associated with the Veteran's service-connected prostate cancer. In sum, the Board finds that the Veteran's 30 percent disability rating under Diagnostic Code 7323 must be restored, effective August 14, 2012. Furthermore, effective November 27, 2009, a 20 percent disability rating is warranted for the Veteran's urinary frequency and, effective November 20, 2017, that rating should be increased to 40 percent for voiding dysfunction. However, the Board finds that the preponderance of the evidence is against the assignment of any higher at any other point during the appeal period. Therefore, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). II. TDIU Total disability ratings for compensation may be assigned, in circumstances where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more with sufficient additional disability to bring the combined rating to 70 percent or more. See 38 C.F.R. § 4.16(a). The Veteran's initial formal claim for a TDIU was received on December 30, 2009. However, because entitlement to a TDIU was raised in connection with his claims for increased rating for his service-connected disabilities that was received on November 27, 2009, the Board finds that his claim for a TDIU stems from that claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Given the Board's decision above with respect to restoring the 30 percent disability rating for the Veteran's service-connected prostate cancer residuals manifested by radiation colitis, effective August 14, 2012; as well as awarding a separate 20 percent disability rating for service-connected prostate cancer residuals manifested by urinary frequency and voiding dysfunction with erectile dysfunction, effective November 27, 2009, the Board notes that he now meets the schedular criteria for a TDIU from November 27, 2009. Indeed, from that date, the Veteran has been awarded service connection, in pertinent part, for the following disabilities: radiation colitis (as a residual of prostate cancer), rated as 30 percent disabling; urinary frequency and voiding dysfunction with erectile dysfunction (as a residual of prostate cancer), rated as 20 percent disabling; and diabetes mellitus, rated as 20 percent disabling. Under 38 C.F.R. § 4.16(a), because these disabilities stem from a common etiology or origin (herbicide agent exposure), their ratings can be combined for the purposes of establishing schedular eligibility for TDIU. Under 38 C.F.R. § 4.25, they combine to 60 percent, satisfying the schedular eligibility requirement of one disability at 60 percent. To establish entitlement to TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16 (2018). In reaching such a determination, the central inquiry is "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2006); Van Hoose v. Brown, 4 Vet. App. 361 (1993). Marginal employment shall not be considered substantially gainful employment for purposes of entitlement to TDIU. 38 C.F.R. § 4.16(a). Marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Id. Consideration must be given in all claims to the nature of the employment and the reason for termination. Id. In his December 2009 VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, the Veteran stated that he stopped working as teacher in 2009 as a result of his service-connected prostate cancer. His previous work history included working as a teacher for the Department of Corrections from 2006 to 2009, as well as working at a technical college from 2007 to 2009. His educational history included four years of college, as well as a multiple degrees at the university level. The August 2012 VA examiner concluded that the functional impairment associated with the Veteran's disability, frequent bowel movements, interfered with his ability work. In a July 2018 private treatment record, the Veteran's treatment provider then noted that his use of multiple pads throughout the day greatly limited his ability to carry out many of his regular daily activities, such as working for any period of time and not having immediate access to the bathroom or the ability to change his clothes immediately. A July 2018 letter from a different treatment provider noted that the Veteran's inability to control his loss of stool was very disabling for any occupational or social situation. During his August 2018 testimony before the undersigned Veterans Law Judge, the Veteran then testified that he had to stop teaching as a result of the functional impairment associated with his disabilities; however, he also testified that he was working part-time at a local church as a minister. The examinations in September 2019 noted that the Veteran's need to be near a bathroom for frequency toileting had an impact on his ability work. Similarly, the February 2020 examiner noted that the Veteran was unable to be too far from a bathroom, and that he could not perform any occupation requiring remote work or work away from a restroom. Based on the foregoing, and after resolving all reasonable doubt in his favor, the Board finds that the Veteran's service-connected disabilities rendered him unable to secure or follow gainful employment from at least November 27, 2009, such that entitlement to a TDIU is warranted from that date. Significantly, the Board finds that functional impairment associated with the residuals of the Veteran's prostate cancer such as having to use multiple pads throughout the day, as well as having to change his clothes due to urinary and/or fecal leakage would greatly limit his ability to carry out substantially gainful employment. These functional limitations are further echoed by the Veteran's private treatment providers, as well as the August 2021, September 2019, and February 2020 examiners. Given these limitations, his education, and his work history, the Board finds that the Veteran would be unlikely to find and maintain employment in any capacity. Although the evidence demonstrates that the Veteran has been working as a part-time pastor during the appeal period, the key question here is whether his employment should be considered "marginal," as referenced in 38 C.F.R. § 4.16(a). If the evidence or facts reflect that a veteran is capable only of marginal employment, he is incapable of securing or following a substantially gainful occupation and is therefore entitled to TDIU if his service-connected disabilities are the cause of that incapability. See Cantrell v. Shulkin, 28 Vet. App. 382, 387-88 (2017). Given the Veteran's reported earnings, see February 2019 VA Form 21-8940; October 2019 VA Form 21-8940, and the fact that they do not exceed the poverty thresholds for 2019, see http://www.census.gov/data/tables/ time-series/demo/income-poverty/historical-poverty-thresholds.html, the Board finds that his employment as a part-time pastor does not constitute substantially gainful employment. In view of the foregoing, the Board finds that entitlement to a TDIU is warranted, effective November 27, 2009. The Board has considered the benefit-of-the-doubt rule in granting this benefit. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James R. Springer, 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.