Citation Nr: 21076903 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 16-28 017 DATE: December 28, 2021 ORDER Entitlement to service connection for erectile dysfunction, to include as secondary to chronic laryngitis, tinnitus, painful surgical scars, bilateral hearing loss, or tension headaches, is denied. Entitlement to service connection for hypertension, to include as secondary to chronic laryngitis, tinnitus, painful surgical scars, bilateral hearing loss, or tension headaches, is denied. Entitlement to service connection for coronary artery disease, to include as secondary to hypertension, is denied. REMANDED Entitlement to service connection for gout, also claimed as a toe condition, is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. FINDINGS OF FACT 1. Erectile dysfunction is not shown to be causally or etiologically related to any disease, injury, or incident of active service, to include any service-connected disability. 2. Hypertension is not shown to be causally or etiologically related to any disease, injury, or incident of active service, to include any service-connected disability; and did not manifest to a compensable degree within one year of separation from active service. 3. Coronary heart disease is not shown to be causally or etiologically related to any disease, injury, or incident of service, to include any service-connected disability; and did not manifest to a compensable degree within one year of separation from active service. CONCLUSIONS OF LAW 1. The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1111, 1112, 1117, 1131, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for coronary heart disease have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1973 to May 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2014 and May 2014 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the Board remanded the Veteran's claims of entitlement to service connection for gout, coronary artery disease, hypertension, erectile dysfunction, headaches, and a psychiatric disorder for additional development. In a September 23, 2021 rating decision, the RO granted service connection for headaches with a noncompensable rating, effective April 10, 2013. In October 2021, the Veteran submitted a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), thereby appealing the initial rating assigned for the headache disability. Accordingly, such claim has been withdrawn from the instant legacy appeal and will be adjudicated separately under the Appeals Modernization Act (AMA). The remaining service connection claims now return for further appellate review under the legacy system. SERVICE CONNECTION Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as cardiovascular-renal disease, to include hypertension, to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (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. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for erectile dysfunction, to include as secondary to chronic laryngitis, tinnitus, painful surgical scars, bilateral hearing loss, or tension headaches. The Veteran seeks service connection for erectile dysfunction. As an initial matter, the Board notes that the Veteran has a current diagnosis of erectile dysfunction, as of May 2021. The Veteran has not claimed specifically that his erectile dysfunction has onset during service. However, he has mentioned that such disorder might be secondary to one or more of his service-connected conditions. Accordingly, the question remains whether the Veteran's current erectile dysfunction is related, to include on a secondary basis, to his military service. Turning to the evidence of record, the Veteran's service treatment records (STRs) show that he sought treatment in May 1976 for an enlarged lymph node of the left groin area, with pain on palpation, which was initially assessed as a possible hernia but then aspirated a few days later. In July 1979, the Veteran received treatment for a penile wart. In August 1984, he reported perianal itching with occasional bleeding and was given a provisional diagnosis of idiopathic pruritis, ruling out abcess/fissure. He again sought treatment the following May for penile discharge. He then sought treatment for hemorrhoids and fissures in May 1991. By the time of his discharge from service, the Veteran stated that he was in good health and failed to report any male reproductive system symptoms. Thereafter, VA medical treatment records acknowledged the Veteran's report of erectile dysfunction to a provider in December 2004, attributing the condition to his other physical conditions. The Veteran was afforded a male reproductive VA examination in July 2013, at which time the examiner acknowledged the Veteran's report of having a knot in his groin area beginning in 1980. However, the Veteran declined a physical examination, and a thorough interview of the Veteran revealed no formally diagnosed male reproductive system condition, to include erectile dysfunction. No voiding dysfunction, retrograde ejaculation, infection, tumor, neoplasm, or any other pertinent physical findings or symptoms were noted. The Veteran was afforded another VA examination in September 2021 to evaluate his claimed erectile dysfunction, at which time he again declined any physical examination. The Veteran's diagnosis of erectile dysfunction was, this time, acknowledged following an interview, with a noted onset date of May 2021. The examiner went on to evaluate the etiology of the Veteran's erectile dysfunction, noting that the condition is less likely than not related to the Veteran's military service, to include having onset during service or being secondary to any service-connected condition. In this regard, the examiner reviewed the Veteran's pertinent STRs and concluded that the Veteran had no in-service or immediate post-service history or diagnosis of erectile dysfunction, even considering the treatment for resolved idiopathic perianal and groin region conditions. The examiner specifically discussed the Veteran's service-connected conditions of chronic laryngitis; tinnitus, to include associated symptoms of tension headaches; bilateral hearing loss; and painful surgical scars, finding that none could be considered even a predisposing factor, much less a more likely cause or aggravating factor of erectile dysfunction. Accordingly, the examiner found no causation or aggravation of the Veteran's erectile dysfunction by any service-connected condition. Regarding the prior comment in 2004 that the Veteran's erectile dysfunction might be due to his medical conditions, the Board notes that corresponding medical treatment records from 2004 through the course of the appeal discussed erectile dysfunction in the context of treatment for both diabetes and coronary artery disease, for which the Veteran has not been service-connected, as will be discussed infra. Furthermore, no records actually provide any discussion or rationale regarding the possible connection between the Veteran's erectile dysfunction and any of his other medical conditions. Accordingly, the Board notes that the September 2021 VA examiner is the only examiner of record who considered and discussed in detail the Veteran's claimed association between his erectile dysfunction and his service-connected conditions. Accordingly, the Board affords great probative weight to this September 2021 VA examiner's opinion, as such considered all of the pertinent evidence of record, to include the statements of the Veteran and relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Notably, there is no medical opinion to the contrary. In this regard, the Board acknowledges that the Veteran believes that his current erectile dysfunction is related to his military service. However, while lay persons are competent to provide opinions on some medical issues, in this case, the cause of erectile dysfunction falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Specifically, such matter involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. In this regard, determining the etiology of erectile dysfunction requires medical training and knowledge of the male reproductive system. Moreover, whether the symptoms the Veteran reportedly experienced during or after service are in any way related to his currently diagnosed erectile dysfunction is also a matter that also requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Accordingly, the Veteran's opinion as to the etiology of his erectile dysfunction is not competent evidence and, consequently, is afforded no probative weight. Based on the foregoing, the Board finds the Veteran's erectile dysfunction is not shown to be causally or etiologically related to any disease, injury, or incident during service and is not shown to be caused or aggravated by any service-connected condition. Thus, service connection for such disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for service connection for erectile dysfunction. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. 2. Entitlement to service connection for hypertension, to include as secondary to chronic laryngitis, tinnitus, painful surgical scars, bilateral hearing loss, or tension headaches. 3. Entitlement to service connection for coronary artery disease, to include as due to hypertension. The Veteran contends that his currently diagnosed hypertension and coronary artery disease are related to his military service. In his December 2013 claim, the Veteran stated that his hypertension might be due to his service-connected disabilities, and his coronary artery disease might be due to his hypertension. As was noted in the December 2018 Board decision, the Veteran's STRs include a March 1993 electrocardiogram, which showed sinus bradycardia and early repolarization. After service, the Veteran experienced an acute myocardial infarction in January 2004. Thereafter, in June 2007, the Veteran was assessed with asymptomatic coronary arteriosclerosis via electrocardiogram findings of early repolarization with premature ventricular contraction. Evidence of record shows current diagnoses of both hypertension and coronary artery disease, as of May 2021. However, prior to the Board 2018 remand, the Veteran had not been provided a VA examination to evaluate the etiology of such disorders. As an initial matter, the Board also notes that the Veteran's numerous in-service blood pressure measurements failed to show any abnormal readings or in-service diagnosis of hypertension, which must be confirmed by readings taken two or more times on at least three different days for VA disability purposes. Furthermore, at the time of separation from service, the Veteran reported that he was in good health and his blood pressure was recorded as 136/88. The Veteran was afforded VA examinations in September 2021 to evaluate the etiology of his currently diagnosed hypertension and coronary artery disease. The examiner noted current diagnoses but also found that neither disorder was related to his military service, on a direct or secondary basis. In this regard, the September 2021 examiner specifically addressed the in-service electrocardiogram results and explained that such pattern reported predominates among young and fit individuals with slow heart rates, and that such has generally been viewed by medical professionals as a marker of good health. The examiner found no diagnoses during service or in the year following service indicative of hypertension or coronary artery disease, or any other evidence suggestive of a nexus between his current cardiovascular disorders and his service. Regarding whether a service-connected disability could have proximately caused or aggravated his hypertension, the examiner specifically considered each of his service-connected disabilities and their resulting symptomatology and found no connection in terms of causation or aggravation. He concluded that none served as even a predisposing risk factor for the development of hypertension. Regarding the Veteran's coronary artery disease, the examiner also found that the most likely risk factors in the Veteran's specific case included the non-service connected conditions of diabetes mellitus, hypertension, and hypercholesterolemia. The Board notes that the Veteran has argued that his coronary artery disease should be service-connected, as he believes such to be secondary to hypertension. However, as the Board herein denies service connection for hypertension, service connection for coronary artery disease cannot be granted secondary to hypertension. The Board affords great probative weight to the September 2021 VA examiner's opinions, as such considered all pertinent evidence of record, to include the Veteran's contentions and his relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez, 22 Vet. App. at 304; Stefl, 21 Vet. App. at 124. The Board also considered the Veteran's assertions as to the etiology of his hypertension and coronary artery disease. However, as a lay person, he does not have the requisite training and experience necessary to address such a complex medical matter. Jandreau, 492 F.3d at 1377; Woehlaert, 21 Vet. App. at 462. In this regard, the diagnosis and etiology of such disorders involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship and, thus, may not be competently addressed by lay statements. Therefore, the Veteran's opinions as to the onset and etiology of his hypertension and coronary artery disease is not competent evidence and cannot be afforded probative weight. Furthermore, the evidence of record fails to demonstrate that cardiovascular-renal disease, to include hypertension, manifested to a compensable degree within one year of separation from service in May 1993. Consequently, presumptive service connection for such disorders is not warranted. Therefore, the Board finds that hypertension and coronary artery disease are not shown to be causally or etiologically related to any disease, injury, or incident during service; are not proximately caused or aggravated by any service-connected disability; and did not manifest to a compensable degree within one year of separation from service. Thus, service connection for such disorders is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims for service connection for coronary artery disease and hypertension. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. REASONS FOR REMAND 1. Entitlement to service connection for gout, also claimed as a toe condition. The Board remanded the Veteran's claim of entitlement to service connection for gout in December 2018. In this regard, the only VA opinion addressing gout stated that the Veteran did not have any diagnosis of the foot. However, multiple medical treatment records noted gout in the Veteran's personal medical history and assessments. Furthermore, an STR from January 1992 documented big toe pain with edema, noted to be "possible gout." The Veteran was afforded a new VA examination in March 2021; however, such opinion was inconsistent and, therefore, inadequate. Specifically, the examiner noted that the Veteran was diagnosed with gout in 1992prior to separation from servicebut then stated that the Veteran did not have an in-service diagnosis of gout. Furthermore, the examiner noted that he was unable to find the relevant STR, which the Board specifically requested that he consider and reconcile with his findings. Finally, the examiner did not include consideration of the Veteran's relevant lay statements regarding the onset of his gout. Accordingly, an addendum opinion must be obtained. 2. Entitlement to service connection for an acquired psychiatric disorder. The Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, to include PTSD, was remanded in December 2018 to afford the Veteran a VA examination. The December 2018 Board remand noted that the evidence of record reflected diagnoses of mood, nightmare, and depressive disorders. Accordingly, the remand instructions required the examiner to identify all current psychiatric diagnoses and reconcile such findings with the evidence of record. Further, for each disorder, the examiner was directed to state whether it is as likely as not that such originated during service or is otherwise etiologically related to service. While the Veteran was afforded a VA psychiatric examination in August 2021, the examiner only addressed the Veteran's claimed PTSD. He failed to address the other diagnoses of record, as was specifically required in the remand instructions. Therefore, another remand is necessary in order to obtain an addendum opinion that complies with the December 2018 remand directives and addresses all relevant psychiatric diagnoses of record. Stegall v. West, 11 Vet. App. 268, 271 (1998). Finally, the Board also notes that VA treatment records from July 2014 mention alcohol dependence, and the Veteran has argued that his chronic consumption of alcohol has been self-treatment of his service-related emotional problems. As such was not considered by the August 2021 examiner, it should be evaluated in the issuance of the addendum opinion. The matters are REMANDED for the following action: 1. Return the record, to include a copy of his remand, to an appropriate VA examiner to address the nature and etiology of the Veteran's currently diagnosed gout. The claims file must be made available to the VA examiner. Following a review of the record, the examiner must opine whether the Veteran's gout is at least as likely as not related to an in-service injury, event, or disease, including the January 1992 in-service report of toe pain with edema, assessed as "possible gout." A rationale for any opinion offered should be provided. 2. Return the record, to include a copy of his remand, to an appropriate VA examiner to address the nature and etiology of the Veteran's claimed acquired psychiatric disorder. Following a review of the record, the examiner should address the following inquiries: 3. Identify all acquired psychiatric disorders other than PTSD that meet, or have met, the DSM-5 diagnostic criteria at any time since the Veteran's June 2012 claim, or in close proximity thereto, to include any mood or depressive disorder, and any nightmare-related disorder. 4. For each currently diagnosed acquired psychiatric disorder other than PTSD, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder had its onset in, or is otherwise related to, the Veteran's military service, to include his reported self-medication with alcohol. (Continued on the next page) A rationale for any opinion offered should be provided. CLAIRE M. DAVIDOSKI Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Breckenridge 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.