Citation Nr: 21012150 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 15-06 705 DATE: March 3, 2021 REMANDED Entitlement to service connection for benign prostatic hypertrophy, claimed as prostate problems, to include as secondary to service connected posttraumatic stress disorder (PTSD) and erectile dysfunction, is remanded. REASONS FOR REMAND The Veteran served in the United States Army Reserve. He had a period of active duty for training (ACDUTRA) from July 1987 to November 1987 and a period of active duty from November 1990 to April 1991. This matter comes before the Board of Veterans’ Appeals (Board) from a July 2012 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). This case was previously before the Board in January 2018 and June 2020, when it was remanded for further development. In June 2020, the Board remanded the instant matter for additional development to include obtaining an etiology opinion and associating updated VA treatment records with the file. Updated VA treatment records have been associated with the record and a VA etiology opinion was obtained in November 2020. In addition, in a June 2020 letter, the Veteran was asked to complete an authorization form to allow VA to obtain reports from private providers; however, the Veteran did not respond to this letter. 1. Prostate Disorder The Veteran seeks service connection for a prostate disorder, which he asserts is the result of serving in the Gulf War, burning of human waste, exposure to smoke from burning oil rigs, and the experimental drugs he was given in active service. See VA Form 9, received by VA February 23, 2015. In the alternative, he alleges that his prostate disorder was caused or aggravated by his service connected PTSD and/or erectile dysfunction. The Veteran’s service treatment records (STRs) do not show a diagnosis of, or treatment for, a prostate disorder, and/or an undiagnosed illness. The Veteran did not complain of a prostate disorder and/or an undiagnosed illness during his time in service. See STRs. The Veteran’s VA treatment records note that he had a history of hypertrophy (benign) of prostate without urinary obstruction and other lower URI and benign adenoma of prostate. See VA treatment records, April 24, 2019. The date of his diagnosis was unknown, and it was noted to be in the 1990s. See Male Reproductive System Conditions Disability Benefits Questionnaire (DBQ), February 28, 2017. The Veteran underwent an examination in May 2012. See General War General Medical Examination DBQ, May 17, 2012. The examiner related that the Veteran did not experience any diagnosed illnesses for which no etiology was established. The examiner noted that the Veteran was diagnosed with prostate hypertrophy at an unknown date. The examiner also opined that the Veteran’s claimed disorder was not related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The Veteran underwent another examination in February 2017. See Male Reproductive System Conditions DBQ, February 28, 2017. The examiner opined that the Veteran was diagnosed with benign prostate hypertrophy (BPH) in the 1990s. The Veteran related that he was diagnosed with BPH in 1990, was noted to have intermittent urinary tract infections/prostatitis, and was evaluated by his doctor for symptoms of urinary frequency and dribbling. He related that he has been on Flomax with a decrease in his symptoms. The examiner opined that the Veteran’s prostate disorder was less likely as not proximately due to, or the result of, his service-connected disability, as it was medically unclear what caused the prostate to enlarge, and that the disorder might be due to changes in the balance of sex hormones as men grow older. As such, there was no evidence between the Veteran’s service-connected PTSD and his claimed prostate disorder. In its June 2018 remand, the Board found that the May 2012 examiner relied solely on the absence of any STRs records for a prostate disorder, and that, as the result, the examination was inadequate as to the nexus opinion regarding the Veteran’s claimed prostate disorder. The Board determined that an additional medical opinion was needed to address direct service connection and secondary service connection. The Veteran was afforded a VA examination in September 2019. See Male Reproductive System Conditions DBQ, September 23, 2019. The examiner related that the Veteran’s prostate was normal, that his condition began in 2007 with difficulty urinating and abnormal libido, and that the Veteran took Flomax for the prostate disorder. The examiner opined that the Veteran’s prostate disorder was less likely than not aggravated beyond its natural progression by military service, as there are no medical records showing a diagnosis or treatment for the disorder or any prostate disorder in service. The examiner also opined that there were no direct pathophysiologic or medical studies that showed that BPH is aggravated by being in the military. The Board, in its June 2020 remand, found that the September 2019 examiner did not address related whether the prostate disorder could be related to any exposures during the Veteran’s service in Southwest Asia, including exposure to smoke from burning oil fields and the burning of human waste. See VA Form 9, received by VA February 23, 2015. The Board found that the examiner also did not discuss the aggravation prong of secondary service connection, as he instead provided an opinion regarding the aggravation of a preexisting disorder. See 38 C.F.R. § 3.310; El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). The Board determined that an additional medical opinion was needed. The Veteran underwent the most recent VA examination in November 2020. See Male Reproductive System Conditions DBQ, November 3, 2020. The examiner confirmed that the Veteran was diagnosed with prostate gland hypertrophy in 2007. The Veteran related that he experienced multiple infections in 2007. The examiner opined that the Veteran’s prostate disorder was less likely than not incurred in or caused by his active service. The examiner reasoned that there were no medical records that substantiated an in-service onset, and therefore a nexus could not be made. The examiner opined that the Veteran’s prostate disorder was less likely than not proximately due to or the result of the Veteran’s service-connected condition, as there was no literature that substantiated a causal relationship between a prostate disorder and PTSD and/or erectile dysfunction. Finally, the examiner opined that the Veteran’s prostate disorder was less likely than not aggravated by his service-connected PTSD and/or erectile dysfunction, as there was no medical literature which would support such a connection. The examiner also concluded that the Veteran’s claimed disorder and symptoms were attributable to a diagnosed condition. However, the November 2020 VA examiner relied entirely upon the absence of in-service medical records to support the negative etiology opinion. See, e.g., Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a Veteran's reports of in-service injury and instead relied on the absence of evidence in a Veteran's service treatment records to provide a negative opinion). Moreover, the November 2020 examiner failed to provide an adequate rationale for the opinions provided. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Finally, the November 2020 VA examiner failed to address the Veteran’s specific contentions regarding his in-service environmental exposures. The AOJ did not obtain an opinion which would allow for adjudication of this claim. Compliance with a Board remand directive is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268 (1998). As such, this case must be once again remanded and sent out for an opinion. In sum, multiple medical opinions in this matter exist in the claims file, all of which are inadequate and do not allow the Board to answer the basic question before it – whether the Veteran experiences a prostate disorder that is related to his active service and/or service-connected PTSD and/or erectile dysfunction. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, forward the Veteran’s record to an appropriate examiner to address the following questions. The examiner must provide all findings, along with a complete rationale for the opinion(s) in the examination report. The need for further physical examination is left to the discretion of the examiner. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. The examiner should respond to the following: (A) Is it at least as likely as not (i.e., probability of 50 percent or greater) that the diagnosed prostate disorder had its onset in service, or is etiologically related to the Veteran’s active duty service? The examiner should specifically consider whether the Veteran’s prostate disorder is related to his Southwest Asia service and environmental exposures during such service, including smoke from burning oil fields and the burning of human waste. (B) Is it at least as likely as not (i.e., probability of 50 percent or greater) that the diagnosed prostate disorder was caused or aggravated by the Veteran’s service-connected PTSD and/or erectile dysfunction? Address both the causation and aggravation questions in the rationale. In other words, even if the Veteran’s service-connected disabilities did not cause his current prostate disorder, please should still address whether they could have worsened his prostate disorder. (Continued on the next page)   A rationale for any opinion offered should be provided. As part of this rationale, please identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). A discussion of the facts and medical principles involved would be of considerable assistance to the Board. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Lech, 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.