Citation Nr: A21019946 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 210817-178692 DATE: December 14, 2021 REMANDED Entitlement to service connection for impairment of rectal sphincter control (claimed as fecal incontinence) to include as secondary to the service-connected disability of voiding dysfunction, residual of prostate cancer status post prostatectomy is remanded. REASONS FOR REMAND The Veteran served honorably on active duty from January 1969 to June 1975, including service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2020 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2021, the Veteran filed a Decision Review Request: Board Appeal (Notice of Disagreement) (VA Form 10182) and elected the Evidence Lane. Under the evidence lane, the Board reviews the claims based on the evidence of record at the time of the prior rating decision, and evidence received within 90 days following receipt of the NOD. 38 C.F.R. § 20.303. 1. Service connection for impairment of rectal sphincter control (claimed as fecal incontinence) to include as secondary to the service-connected disability of voiding dysfunction, residual of prostate cancer s/p prostatectomy. The Veteran contends that his fecal incontinence is a residual of his service-connected prostate cancer. The Veteran was afforded an examination in August 2020. The VA examiner diagnosed the Veteran with impairment of rectal sphincter control. He noted that the Veteran gave a detailed "history of a recent lumbar spine decompression that was causing fecal incontinence." The examiner then opined that his claimed condition was "less likely than not due to radiation due to prostate cancer and more likely than not due to his lumbar spine compression." Unfortunately, the Board cannot make a fully informed decision because the examination did not address the secondary service connection issue of aggravation. In this regard, although the examiner provided a negative nexus opinion of whether the Veteran's service-connected prostate cancer caused the Veteran's fecal incontinence, the examiner did not provide an opinion on whether his fecal incontinence was aggravated by his prostate cancer. The examiner did not provide separate findings or rationales with respect to the independent questions of causation and aggravation and, instead, focused on the issue of causation. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018) (holding that causation and aggravation are concepts and should have separate findings and rationales). The Board notes that a medical examination report must contain not only clear conclusions with supporting data, but also reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Further, where secondary service connection is asserted, an examination must offer an opinion as to aggravation in addition to direct causation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). Moreover, the Veteran argues, and the Board agrees, that the examiner erred in his finding that the Veteran's claimed condition was due to his lumbar spine condition based on the "anecdotal comment from the Veteran regarding the possibility that a deteriorating disc is the cause of the impairment to the rectal sphincter muscles." See August 2021 Veteran Statement. He further provided articles in support of his claim: It is common knowledge among the medical community that impairment of rectal sphincter control (fecal incontinence) can be a result of radiation from treatment of prostate cancer. Doctors Maeda Y, Hoyer M, Lundby L, Norton C. Faecal, from the National Institute of Health, in their article "incontinence following radiotherapy for prostate cancer: a systematic review. Radiotherapy and Oncology. 2011 Feb 1;98(2):145-53" The article further states: It is reported that over 50% of men experience a varying degree of faecal incontinence after radiation therapy for their prostate cancer See also "Effects of radiation therapy on the structure and function of the pelvic floor muscles of patients with cancer in the pelvic area: a systematic review. Journal of Cancer Survivorship. 2016 Apr 1; 10(2):351-62, by doctors Bernard S, Ouellet MP, and Moffet H, Roy Js, Dumoulin C. As such, the matter must be remanded for an addendum medical opinion that addresses both causation and aggravation elements of secondary service connection with adequate rationale. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). While one the effects of the AMA is to narrow the set of circumstances in which the Board must remand appeals for further development instead of adjudicating them directly, even under the AMA, the Board still has the duty to remand issues when necessary to correct a pre-decisional duty to assist error. See Pub L. No. 115-55 section (2)(d); 38 C.F.R. § 20.802 (a) (2019). Such a pre-decisional duty to assist error was incurred with respect to the August 2020 VA examination. The matter is REMANDED for the following actions: 1. Obtain an opinion from an appropriate examiner regarding the Veteran's claim. The examiner is asked to answer the following: a. Is it at least as likely as not the Veteran's fecal incontinence is caused or aggravated (beyond natural progression) by the Veteran's service-connected prostate cancer. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation (specifying the baseline level of disability and current level of severity, based on consideration of VA's rating schedule). 2. The examiner must discuss the articles cited by the Veteran. 3. All opinions provided should be thoroughly explained, and a complete and detailed rationale for any conclusions reached should be provided (a bare conclusory statement will be deemed inadequate) MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kelsey Love, Associate 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.