Citation Nr: 21073603 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 17-57 804 DATE: December 9, 2021 REMANDED Entitlement to a compensable rating for service-connected left-sided varicocele condition is remanded. Entitlement to a total disability evaluation based upon individual unemployability is remanded. REASONS FOR REMAND The Veteran had honorable active-duty service with the United States Marine Corps from December 1974 to April 1975. This matter is before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing has been associated with the Veteran's electronic claims file. This matter has previously been remanded on multiple occasions, to include most recently, in May 2021. Regrettably, an additional remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the appellant's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2020). Entitlement to a compensable rating for service-connected left-sided varicocele condition is remanded. Although the further delay entailed by remand is regrettable, current adjudication of the Veteran's claims would be premature. Undertaking additional development prior to a Board decision is the only way to ensure compliance with the duty to assist, as required. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2020). Pursuant to a May 2021 decision, the Board concluded that clarification was required as to the conflicting medical evidence on whether the Veteran's service-connected left varicocele had resolved. In response thereto, the Veteran was afforded a VA examination of male reproductive organs in August 2021. At that time, a current diagnosis of left varicocele was noted. During the clinical interview, the Veteran reported that he was assaulted in boot camp and was treated at a Naval hospital. He was diagnosed with left varicocele. Thereafter, he experienced intermittent daily pain. Follow-up ultrasounds in 2014, 2015, and 2021, documented the visualization of varicoceles bilaterally. At its worst, pain was rated as 5 or 6 on a 10-point scale. "Moving wrong" and climbing stairs aggravated his pain. Occasionally, pain disturbs his sleep. Continuous medications were not required to treat the Veteran's symptoms. To date, an orchiectomy was required. Negative responses were recorded regarding the presence of a renal or voiding dysfunction. Although the Veteran endorsed symptoms of erectile dysfunction (ED), oral medications were not required to treat his symptoms. The examiner suggested that the Veteran's ED could not be attributed to a residual of his service-connected varicocele. There was no evidence of retrograde ejaculation, or a history of chronic epididymitis, epididymo-orchitis or prostatitis. On physical examination of the genitals, a visible abnormality impacted the testes. Pain to palpation and tenderness was deemed likely related to palpation of the varicocele, bilaterally. At the Veteran's request, a prostate examination was not conducted. No benign or malignant neoplasms were observed. A testicular biopsy was not performed in connection with this examination. In August 2021, an ultrasound of the scrotum and testicles revealed borderline bilateral varicoceles. Vascular flow of the testes appeared unremarkable. In the comments section, the examiner documented the Veteran's lay reporting of a recent urology examination due to urinary leakage, a weak stream, and an increased voiding frequency over the last 1-2 months. Reportedly, a change in intake patterns was suggested. In a separate opinion, dated the same month, the examiner reported disagreement with the April 2021 VA examiner conclusion's that the Veteran's service-connected left varicocele had resolved. In support of the stated finding, the opinion noted that ultrasound findings, dated August 2021, confirm a current diagnosis of borderline varicocele. A small bilateral varicocele was also observed on previous ultrasounds in 2014 and 2015. A physical examination produced visible pain upon palpation bilaterally. Other symptoms, including urinary leakage, frequency, and weakened stream have resolved over the previous month due to treatment with a urologist. Therefore, the examiner opined that it is less likely than not that the Veteran's urinary problems are causally related to his left varicocele. Again, the Board finds the VA examiner's opinion inadequate. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In reaching the stated conclusion, the Board observes that the Veteran was evaluated in emergency room for abdominal pain in May 2021. No acute abnormalities were observed on physical examination. However, a computerized tomography (CT) scan of the abdomen and pelvis (with contrast) showed an enlarged prostate and outlet obstruction. Current diagnoses included prostatomegaly, urinary retention, and a urinary tract infection (UTI). A referral to urology was indicated. To treat his symptoms, the Veteran was prescribed oral medication, Tamsulosin. In July 2021, the Veteran was evaluated by a urologist. During the clinical interview, he reported a history of left testicular pain status/post varicocele repair in 1977. Reportedly, an orchiectomy was recommended 6 years earlier, but he declined. The Veteran also declined oral medication to treat his erectile dysfunction. A current interest in more aggressive treatment options was reported. In particular, the Veteran reported increasing pain, discomfort, increased urinary frequency, urgency to void, incomplete emptying, and weakened stream. Some straining or forcing was also noted. Recommended treatment options included prescription medications including, Terazosin or Tamsulosin, dihydrotestosterone blockers (e.g., Finasteride), or surgery (e.g., a transurethral resection of the prostate (TURP)). Considering the above, the Board notes that the VA examiner failed to comment on the identified evidence or attempt to resolve the conflicting findings documented in previous VA opinions. Moreover, the examiner's opinion was internally inconsistent within itself. Specifically, the Board notes that the examiner indicated that the Veteran does not suffer from a voiding dysfunction. However, the comments section specifically noted complaints of increased urinary frequency, urinary leakage and a weakened stream over the previous few months. Further, no rationale was provided for the opinion that the Veteran's erectile dysfunction is unrelated to his service-connected varicocele. Considering the above, substantial compliance with the Board's previous remand directives has not been achieved. Therefore an additional remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Additionally, the Board notes that the August 2021 VA opinion was provided by a nurse practitioner. If possible, an opinion of a urologist is recommended. 1. Entitlement to a total disability evaluation based upon individual unemployability is remanded. The Board finds that the Veteran's claim of entitlement to a TDIU is inextricably intertwined with his increased rating claim. As that claim has been remanded as noted in Section 1, adjudication must be deferred pending completion of the additional development requested. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine the current severity of his service-connected left varicocele. If possible, the examination should be conducted by a urologist. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. The examiner must also discuss the functional effects of the Veteran's service-connected left varicocele, and any related residual conditions. As a part of the examination and/or opinion, the examiner must consider all medical evidence to include the Veteran's lay statements. The examiner is specifically requested to review and comment to the conflicting opinions of record and resolve any conflict, if possible. Any inability to do so should be specifically noted and supported by adequate rationale. Any opinion offered must be accompanied by a complete rationale, to include consideration of all medical evidence and lay statements. If any requested opinion cannot be offered without resorting to speculation, the examiner should indicate such in the examination report and explain why a non-speculative opinion cannot be offered. The examiner should also identify what, if any, additional information or evidence would allow for a more definitive opinion. 2. Thereafter, Thereafter, re-adjudicate the Appellant's claims, to include the inextricably intertwined claim for TDIU. If any benefit sought remains denied, provide the Veteran with a supplemental statement of the case and an adequate opportunity to respond before returning the matter to the Board for further adjudication, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires all claims remanded by the Board or by the United States Court of Appeals for Veterans Claims to be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, 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.