Citation Nr: 21008589 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 19-10 952 DATE: February 17, 2021 REMANDED Entitlement to service connection for a bladder condition, to include interstitial cystitis, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1983 to July 1985. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a January 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2020, the Veteran testified before the undersigned Veterans Law Judge at a Board virtual tele-hearing. A transcript of the hearing is of record. The Board previously remanded this matter in August 2020 for additional development. Unfortunately, as explained below, the Board is not satisfied that there was substantial compliance with its prior remand; therefore, the appeal must be remanded once again. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). Entitlement to service connection for a bladder condition, to include interstitial cystitis, is remanded. The Veteran seeks service connection for a bladder condition, to include diagnoses of urinary incontinence, overactive bladder, recurrent urinary tract infections, and interstitial cystitis. She testified at the July 2020 Board hearing that she began having symptoms of bladder problems during service following a violent sexual assault. Service treatment records show that the Veteran sought treatment in service for abdominal pain, bowel problems, and irregular menses. However, at the hearing, the Veteran stated that she also suffered other symptoms during service related to her bladder that she did not know how to identify at the time. She contends that her symptoms started out mild during service and have progressively worsened ever since. Pursuant to the August 2020 Board remand, the Veteran underwent a VA medical examination in December 2020. Upon examination, the VA examiner opined that the Veteran’s bladder problems and cystitis are less likely than not related to her active duty service, to include military sexual trauma, finding that the medical evidence indicates an onset of symptoms in approximately 1993. The Board finds this opinion to be inadequate because the examiner did not consider the Veteran’s competent lay assertions of an in-service onset of symptoms following a sexual assault, nor did the examiner discuss pertinent service treatment records showing treatment for abdominal pain and other potentially relevant symptoms during service. Furthermore, the Board notes that, in the medical opinion, the VA examiner cited to medical literature to explain that the exact etiology of interstitial cystitis remains unknown; however, she stated that “[t]here are also numerous articles showing an association with various mental disorders and coexisting functional disorders, such as fibromyalgia.” The medical literature cited by the examiner raises the possibility that the Veteran’s bladder condition, including interstitial cystitis, may be caused or aggravated by her service-connected posttraumatic stress disorder and obsessive compulsive disorder. When a theory of entitlement is raised by the record, the Board must consider it. See Szemraj v. Principi, 357 F.3d 1370, 1375-76 (Fed. Cir. 2004). In light of the above, the Board finds that the Veteran’s claim must be remanded once again because the RO did not comply with the Board’s prior remand directive to obtain an adequate medical opinion on the Veteran’s behalf. See Stegall, 11 Vet. App. at 268. On remand, an addendum medical opinion must be obtained that is adequate for the Board to make an informed decision on the Veteran’s claim. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007); Douglas v. Shinseki, 23 Vet. App. 19, 26 (2009). In this regard, the addendum medical opinion obtained on remand must address the newly-raised theory of entitlement to service connection on a secondary basis. Accordingly, the matter is REMANDED for the following action: Forward the Veteran’s claims file to a qualified VA examiner, who has not yet provided an opinion in this case, to provide an addendum opinion. A full VA examination should not be scheduled unless it is deemed necessary by the examiner or otherwise required by the evidence. The examiner must review the claims file in its entirety, to include a copy of this REMAND, and that review must be noted in the report. Thereafter, the examiner is asked to provide a fully-articulated medical opinion addressing the following: (a) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed bladder condition, to include interstitial cystitis, was incurred in or caused by any in-service disease, event, or injury, to include military sexual trauma? In providing a response to (a), the examiner must specifically consider and address: (i) the Veteran’s hearing testimony that she experienced stomach pain and cramping and other bladder issues during service following a sexual assault; (ii) service treatment records showing that the Veteran sought treatment for abdominal pain, bowel problems, and irregular menses during service; and (iii) the October 2017 opinion by Dr. Parekh regarding the possible link between sexual assault and interstitial cystitis. (b) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed bladder condition, to include interstitial cystitis, is caused by the Veteran’s service-connected posttraumatic stress disorder and obsessive compulsive disorder? (c) Is it at least as likely as not (50 percent or greater probability) that any currently-diagnosed bladder condition, to include interstitial cystitis, is aggravated by (increased in severity beyond its natural progression) the Veteran’s service-connected posttraumatic stress disorder and obsessive compulsive disorder? In providing responses to (b) and (c), the examiner must specifically consider and discuss the medical literature cited by the December 2020 VA examiner suggesting that an association may exist between interstitial cystitis and a mental disorder. The examiner is reminded that the term “at least as likely as not” does not mean “within the realm of possibility.” Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. The examiner is advised that the Veteran is competent to report her medical history, including the onset and continuity of symptoms, and such reports must be acknowledged and considered in formulating any opinion. The Veteran’s lay contentions must be considered and weighed in making the determination as to whether a nexus exists between the claimed disability and military service. The examiner must provide a complete rationale for any opinion offered, citing to the examiner’s own expertise, medical principals, and/or evidence in the Veteran’s claims file, when necessary, to support the conclusion reached. If the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts), or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Melissa Barbee, 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.