Citation Nr: 21011300 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 13-12 448 DATE: March 1, 2021 ORDER Entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected diabetes mellitus, type II (diabetes mellitus) is denied. FINDING OF FACT The Veteran’s erectile dysfunction is neither proximately due to nor aggravated beyond its natural progression by his service-connected diabetes mellitus and is not otherwise related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for erectile dysfunction, claimed as secondary to service-connected diabetes mellitus, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the United States Army from May 1970 to November 1971. This matter appears before the Board of Veterans’ Appeals (Board) on appeal of an October 2009 rating decision of the Regional Office (RO) in St. Petersburg, Florida. The Board most recently remanded the Veteran’s claim in August 2020 for an adequate addendum opinion addressing aggravation. That followed a September 2019 remand from a Joint Motion for Remand (JMR) from the United States Court of Appeals for Veterans’ Claims (Court) for an addendum opinion addressing aggravation. In January 2017, the Board remanded the Veteran’s claim for a VA examination. 1. Entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected diabetes mellitus, type II Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Prinicipi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 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). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran contends that his erectile dysfunction disability is secondary to his service-connected diabetes mellitus. Service treatment records are silent for treatment or a diagnosis of erectile dysfunction, and the Veteran does not allege that the erectile dysfunction began during service. Therefore, the discussion will center on whether it is secondary to his service-connected diabetes mellitus. The Veteran was afforded a VA examination in March 2017. The examiner indicated that the Veteran’s erectile dysfunction was not caused by, and had not been aggravated by, his service-connected diabetes mellitus. She noted that objective evidence indicated that the Veteran’s erectile dysfunction had onset prior to his diagnosis of diabetes mellitus, and review of labs in the CPRS found that his diabetes has been well controlled. The examiner indicated that the Veteran has been receiving medication refills regularly, which would indicate that the medication is continuing to be effective. Based on this, she concluded that the objective evidence finds the absence of aggravation of erectile dysfunction by diabetes mellitus. The examiner noted that the cause of erectile dysfunction was unknown, but that it could possibly be caused by chronic liver disease. She indicated that the Veteran already had significant liver disease, as well as thyroid disease, by the time he began treatment with VA; and that it is not known with absolute certainty that these are the likely causes of erectile dysfunction; however, it is possible. In accord with the Court’s JMR, the Board assigns the March 2017 examiner’s opinion no probative value as to aggravation because the examiner provided an insufficient rationale as to why the fact that the Veteran’s diabetes medication was effective indicated that the diabetes more likely than not did not aggravate his erectile dysfunction. In November 2019, a VA clinician provided an addendum opinion. The clinician concluded that it is less likely than not that the Veteran’s current erectile dysfunction is caused by or a result of his service-connected diabetes. The clinician explained that the Veteran has many other diagnoses in addition to aging that are well known to have side effects of erectile dysfunction including hypertension, PTSD, depression, chronic renal insufficiency, and hepatitis C. The clinician noted the Veteran’s diabetes is well managed and controlled with medication per his medical record. The clinician noted a medical literature review as part of her rationale. The clinician, however, did not address whether the Veteran’s service-connected diabetes aggravated the Veteran’s erectile dysfunction. Following the Board’s August remand, the AOJ obtained an addendum opinion in October 2020. As to aggravation, the examiner simply opined, “ED is the inability to sustain an erection suitable for penetration. A patient either has ED or doesn’t have it, aggravation is not plausible for this condition.” The Board gives no probative weight to this opinion due to its insufficient rationale. See 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.”). The AOJ obtained an additional addendum opinion in October 2020. The examiner provided a thorough rationale for her determination that it is less likely than not that the Veteran’s erectile dysfunction was aggravated beyond a natural progression by his service-connected diabetes mellitus. The examiner noted that there is not objective evidence in the Veteran’s treatment records to indicate a dramatic or progressive worsening of his erectile dysfunction that could be linked to his diabetes condition. The Veteran has other underlying health issues that can cause or contribute to erectile dysfunction such as hypothyroidism, PTSD, and end stage liver disease. VA treatment records indicate that the Veteran’s erectile dysfunction remained adequately addressed by medication. The examiner noted that the Veteran’s erectile dysfunction was treated with Viagra until 2006 when his prescription was switched to Levitra by the VA pharmacist for an undocumented reason. The examiner noted that his subsequent Levitra dosage was increased to 10 mg and then was increased to 20 mg at around the same time that his thyroid medication was adjusted. The examiner noted that the Veteran resumed taking Viagra 100 mg in January 2012 and has remained on Viagra 100 mg as needed despite the progressive worsening of his diabetes mellitus as his liver disease progressed during that same time frame. In a follow up opinion, the examiner clarified that she was not concluding that the Veteran’s erectile dysfunction was caused or aggravated by his PTSD. The examiner noted that the Veteran’s PTSD likely pre-dated his erectile dysfunction symptoms for many years. A 2002 VA psychiatry consultation report indicated that the Veteran stated he had ongoing problems dealing with PTSD since returning from Vietnam. The examiner stated that a 2001 urology consultation note reported that the Veteran stated that his symptoms of erectile dysfunction were present for two years. The examiner noted that this corresponded to the time frame during which the Veteran’s thyroiditis (hyperthyroidism) developed. The examiner state that thyroiditis is medically known to cause erectile dysfunction. Based on this evidence, the Board finds that the Veteran’s claims for service connection must be denied. The Board accords great probative weight to the opinion proffered by the October 2020 VA examiner. The examiner provided a detailed rationale, relying on and citing to the records reviewed. Moreover, she offered clear conclusions with supporting data as well as reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl, supra. Notably, there is no contrary medical opinion of record. The Board also accords probative weight to the opinion proffered by the March 2017 examiner as to causation. Id. Although the Veteran is competent to report his lay-observable symptoms, he has not presented evidence showing that he has the medical background necessary to competently opine that his current colon condition is etiologically related to service. Layno v. Brown, 6 Vet. App. 465, 470 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Further, the Veteran did not submit any private etiological opinions, which makes the October 2020 VA addendum opinions as to aggravation and the November 2019 and March 2017 VA opinions as to causation the only competent etiological opinions of record. The Board notes that in February 2021 the Veteran’s representative submitted links to three websites that discuss erectile dysfunction and diabetes. In some circumstances, medical treatise evidence can constitute competent medical evidence. 38 C.F.R. § 3.159 (a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses). However, treatise evidence must not simply provide speculative generic statements that are not relevant to the Veteran’s claim. Wallin v. West, 11 Vet. App. 509, 514 (1998). Instead, the treatise evidence, “standing alone,” must discuss generic relationships with a degree of certainty “such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion.” Id., (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996) (generic statement about the possibility of a link between chest trauma and restrictive lung disease is too general and inconclusive); Mattern v. West, 12 Vet. App. 222, 227 (1999) (generally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise is too general and inconclusive (quoting Sacks, supra)). In this case, the various articles submitted by the Veteran only provide general information about diabetes and erectile dysfunction. They are not accompanied by any corresponding clinical evidence specific to the Veteran; therefore, they do not reflect a degree of certainty such that, under the facts of this specific case, reflects plausible causality based upon objective facts, rather than on an unsubstantiated lay medical opinion. As such, the Board affords no probative weight to these treatises on the question of etiology. See Wallin, supra; Sacks, supra. In view of the above, the weight of the evidence is against the claim for service connection for erectile dysfunction, including as secondary to service-connected diabetes mellitus. Accordingly, the claim is denied. Absent a relative balance of the evidence for and against the claim, the evidence is not in equipoise and the benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals J. Morgan, Attorney for the Board Department of Veterans Affairs 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.