Citation Nr: 21010524 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 10-21 647 DATE: February 25, 2021 ORDER Entitlement to service connection for bilateral inguinal hernia is denied. FINDING OF FACT Bilateral inguinal hernia did not manifest in service and is not otherwise related to service, to include exposure to mustard gas and dye therein, or to service-connected disability. CONCLUSION OF LAW The criteria for entitlement to service connection for bilateral inguinal hernia have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1973 to March 1977, from May 1979 to April 1989, and from September 1989 to June 1995. This matter initially came before the Board of Veterans’ Appeals (Board) on appeal from a March 2009 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at two separate hearings in support of his claim, initially in 2011 before a Veterans Law Judge (VLJ) who is no longer working at the Board, and before the undersigned VLJ in November 2015. Transcripts of both hearings are of record. This matter was remanded to the agency of original jurisdiction (AOJ) in November 2012, February 2014, and October 2014, and April 2016. The case has returned to the Board for the purpose of appellate disposition. As the AOJ obtained an examination with opinions responsive to the Board’s instructions, the Board finds that the AOJ has complied with its remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for bilateral inguinal hernia The Veteran contends that he is entitled to service connection for bilateral inguinal hernia disability, as he believes that the hernias onset in service and are related to his in-service duties of heavy lifting in carrying, or are due to exposure to mustard gas and dyes in service. In the alternative, the Veteran has also expressed that his inguinal hernias are secondary to his service-connected transurethral resection of a bladder tumor with recurrent urinary tract infections. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). With chronic disease shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To show a chronic disease in service, a combination of manifestations sufficient to identify the disease entity is required, as is sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). However, the Court has established that 38 C.F.R. § 3.303(b), applies to only those chronic diseases listed in 38 C.F.R. § 3.309(a), which does not include hernia. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 U.S.C. § 1101. Service connection may also be granted for a disease first 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). Service connection is also warranted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. 38 C.F.R. § 3.310(b). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Turning to the evidence, the Veteran’s service treatment records do not document any complaint, finding, or diagnosis related to inguinal hernia. Hernia was not indicated on March 1995 retirement examination, and the Veteran denied rupture/hernia on report of medical history at that time. Following discharge from service, private and VA medical records do not note hernia until 2007. On VA examination in August 2006, the examiner specifically indicated that there was no inguinal hernia on examination of the genitalia/rectum. A December 2007 CT scan of the abdomen and pelvis revealed two small bilateral inguinal hernias containing abdominal fat, greater on the right side. The Veteran underwent surgical repair of the bilateral hernias in April 2008, with a clinical history of groin discomfort and increasing bulges in size. In his April 2009 notice of disagreement, the Veteran reported that he was a combat soldier who carried 70-pound equipment all of the time in the field. He also noted that, given all of the surgeries and repetitive scoping he had for his bladder tumor, it was possible that the surgery made a weak spot in the muscle wall and was not detected until later in life. During the Veteran’s February 2011 Board hearing, he testified that he believed that his hernias onset related to lifting and carrying large objects or to various exposures in service. He reported that he carried heavy artillery, which caused strain. He also stated that his hernias could be due to exposure to mustard gas and dye in service, noting that his doctor said that dye was “probably the reason why” for the hernias. The Veteran also expressed his belief that, as with his bladder tumor, the hernias were present and not detected or discovered until much later. He noted that the hernias were very deep at the time of surgical removal. On VA examination in December 2012, the Veteran reported a long history of urologic problems, including bladder cancers, benign prostatic hypertrophy, erectile dysfunction, and frequent urinary tract infections. He stated that he had an MRI in 2008 because of his erectile dysfunction and urinary tract infections, which revealed bilateral inguinal hernias that he had not previously been aware of. He noted that although unaware of the hernias, he had several years of occasional bilateral groin and scrotal discomfort when he walked. He thought the surgery would stop the pain and discomfort, but it continued. The Veteran reported that he was in service for many years, carrying heavy military shells, and was a poison gas instructor for several years. He expressed his belief that the heavy objects he carried, along with the poison gas, caused his hernias. After objective examination, the examiner diagnosed inguinal hernia, noting a date of diagnosis in 2008. The examiner opined that it is less likely than not that the Veteran’s inguinal hernias began in or were the result of his military service, or his mustard gas and dye exposure in service. In so finding, the examiner noted that an inguinal hernia is caused by weakness in the floor of the abdominal/inguinal cavity, or by a congenital defect where the canal did not close up at birth. Inguinal hernias are a mechanical problem that are not caused by or affected by mustard gas or x-ray dyes; it is not related to any environmental factors. According to the claims file, the Veteran was not diagnosed with inguinal hernias while he was in service, and he was not aware of the hernias until he had an MRI in 2008 after he left service. He stated that he had no symptoms related to his hernias, and his groin/scrotal discomfort was not affected by his hernia repairs. Therefore, because there was no documentation that the Veteran’s hernia were diagnosed or related to any environmental exposure in service, and he had no symptoms related to inguinal hernias, it is less likely than not that this hernias were related to his military service or mustard gas or dye exposure. On urology examination at that time, the examining urologist opined that the Veteran’s inguinal hernias have no relation to his genitourinary complaints or history. The hernias were not aggravated by his bladder tumor, and there is no relationship between hernias, recurrent urinary infections, bladder tumors, or erectile dysfunction. During the Veteran’s November 2015 Board hearing, the Veteran reported that he had experienced hernia symptoms in service. He noted that he had to carry heavy artillery, which he believed initiated the hernia and was simply masked by other physical problems, or that his treatment providers in service did not know what they were looking for or did not know how to find it. He indicated that he did not know about the hernias until he underwent MRI after service. The Veteran underwent VA examination again in March 2019, where diagnosis of inguinal hernia again was noted. Based upon examination, discussion with the Veteran, and review of the file, the examiner opined that the claimed bilateral inguinal hernia was less likely than no secondary to service. In so finding, the examiner noted that hernias and symptoms thereof were not present until long after discharge from service. Review of service treatment records failed to document any groin pain or issues while in service. Further, although heavy lifting can be a cause of inguinal hernia, he did not develop any sign of symptoms of hernia until well after discharge when he was no longer doing any heavy lifting. Furthermore, the examiner opined that it is less likely than not that the Veteran’s bilateral inguinal hernias were caused or aggravated by his service-connected bladder disability or treatment thereof, to include as due to any surgeries or as due to any difficulty urinating. The examiner noted that the Veteran did not have any incisional hernia (which could be due to the previous surgery), and difficulties with urination do not cause inguinal hernias, nor does cystoscopy. Inguinal hernias are caused by weakness in the floor of the abdominal/inguinal cavity, or by a congenital defect where the canal did not close up at birth. Cystoscopy would not weaken the inguinal cavity. With respect to direct service connection, there is no credible evidence that the Veteran's inguinal hernias had their onset in service or is otherwise related to service. In this case, the record does not document inguinal hernias for many years after service. The hernias were discovered on CT examination in December 2007, and the Veteran reported that he had been aware of the hernias prior to the imaging studies. Service treatment records and post-service treatment records prior to 2007 do not note hernia or related complaints and the presence of inguinal hernia was specifically denied on VA examination in 2006. The Board notes that the passage of many years between discharge from active service and the documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and any medical complaints or documentation of a claimed disability is a factor that weighs against a claim for service connection). See 38 C.F.R. § 3.303(b). Moreover, the only pertinent medical opinion of record is that of the December 2012 and March 2019 VA examiners, who had a thorough review of all pertinent evidence and found it less likely than not that the Veteran's bilateral inguinal hernia disability had its onset in service or is otherwise related to service, to include the Veteran’s reported duties of heavy lifting and carrying and exposure to mustard gas and dye. Thus, the only credible, probative opinions of record weigh against the claim, and the Veteran has not presented or identified any medical opinion or other competent evidence that, in fact, supports his claim for service connection on a direct basis. The Board has considered the Veteran's contentions to the effect that his inguinal hernias could have started in service but was undiagnosed or not noted due to his bladder tumor and urinary complaints at that time. The Veteran is competent to testify as to his observations, but this testimony must be weighed against the other evidence of record. In this case, the Veteran's current recollections are not consistent with the VA examiner's opinions, which concluded that, based on review of service treatment records and his recorded history, a bilateral inguinal hernia disability did not manifest in service or for many years after. The Board places greater probative weight to the VA opinion as this examiner has greater training and expertise than the Veteran to determine whether the Veteran manifested hernia symptoms in service. The Board further observes that the Veteran's recollections are not supported by the record as service treatment records and post-service medical records do not document hernia or related complaints until many years after service. When the hernias were initially detected in 2007/2008, the Veteran reported “several years” of intermittent symptoms on examination in 2012, but did not date his symptoms back to service. With respect to the claim for service connection on a secondary basis, none of the available treatment records suggests a relationship between the Veteran's inguinal hernias and his service-connected transurethral resection of a bladder tumor with recurrent urinary tract infections, and the only pertinent medical opinion of record is that of the March 2019 VA examiner, who had a thorough review of all pertinent evidence and found it less likely than not that the Veteran's bilateral inguinal hernia was due to or aggravated by the service-connected bladder tumor, to include any urinary difficulty or surgical treatment related to this service-connected disability. Similarly, the December 2012 VA genitourinary examiner concluded that the hernias were not aggravated by his bladder tumor, and there is no relationship between hernias, recurrent urinary infections, bladder tumors, or erectile dysfunction. Again, the only probative opinions regarding secondary service connection weighs against the claim, and the Veteran has not presented or identified any medical opinion or other competent evidence that, in fact, supports his claim. To the extent that the Veteran's relates his inguinal hernias to service or to service-connected disability, he is competent to testify to his observations. However, on the question as to whether the inguinal hernias had their onset in service, or is otherwise related to service or to service-connected disabilities, the specific, reasoned opinion of the VA examiners is of greater probative weight than the more general assertions of the Veteran, even assuming the Veteran's competence to opine on this medical question. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011). Moreover, while the Veteran is competent to report what his doctor told him, a review of these records does not support his hearing testimony that his hernias were caused by his exposure to dye or were onset in service. As such, his lay recounting is accorded little probative value. Accordingly, the claim for service connection for bilateral inguinal hernia must be denied. In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ROBERT C. SCHARNBERGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. E. Wilkerson, 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.