Citation Nr: 21015320 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 16-35 647 DATE: March 17, 2021 ORDER Entitlement to service connection for erectile dysfunction is denied. FINDING OF FACT The Veteran’s erectile dysfunction is not etiologically related to service or secondary to service-connected disability. CONCLUSION OF LAW The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110, 5107; 38C.F.R. §§3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from July 1967 to April 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In January 2021, the Board remanded the claim to obtain a supplemental medical opinion. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 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. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection is permissible, as well, on a secondary basis for disability that is proximately due to, the result of, or chronically aggravated by a service-connected condition. See 38 C.F.R. § 3.310 (a) and (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on this alternative secondary basis, there must be: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Entitlement to service connection for erectile dysfunction. The Veteran contends that his erectile dysfunction (ED) is related to service. Alternatively, he has previously asserted that his ED is related to Non-Hodgkins Lymphoma or due to medication/treatment for service-connected disabilities. Service connection is currently only in effect for tinnitus and left ear hearing loss. The first question before the Board is whether the Veteran’s ED is related to service on a direct basis. In regard to element (1), current disability, post-service examination reports indicate diagnosis of erectile dysfunction. Concerning the second element, medical or lay evidence of in-service incurrence or aggravation of a disease or injury, in reviewing the e-file, there is evidence that the Veteran received in-service treatment for prostatitis. September 1966 service treatment record (STR) showed no report or indication of erectile dysfunction or prostate issues. December 1967 STR showed complaints of testicular pain, with a note of “probable” prostatitis. February 1971 STR showed no report or indication of erectile dysfunction or prostate issues. In a June 2012 private treatment record, the Veteran reported that he had not been able to obtain an erection since his last stem cell transplant. His most recent stem cell transplant was noted as occurring in June 1998. In November 2018, the Veteran’s representative submitted a medical study that relates to the Veteran’s claim: “Chronic prostatitis and erectile dysfunction results from a cross-sectional study.” In considering the third element, nexus, the record contains an October 2020 VA examination. A diagnosis of erectile dysfunction was confirmed. The examiner opined that the Veteran’s ED was less likely than not (less than 50 percent probability) related to military service. The examiner stated that the Veteran had testicular pain and possible prostatitis per December 1967 STR and had a ‘normal’ GU system on February 1971 separation exam. The examiner stated that the Veteran and his wife clearly report his ED issues started after he received high dose chemotherapy for treatment of his Non-Hodgkins Lymphoma in 1998. The examiner stated that it is well known in the medical literature that many chemotherapy drugs can cause ED issues that are long lasting as a side effect. The examiner explained that the ED issues are 27 years after military discharge and given the above, there is ‘not’ ample evidence to support this claim. Upon remand, a supplemental opinion was obtained in January 2021. The examiner referenced a December 1967 record, wherein the Veteran was noted to have testicular pain and possible prostatitis. The examiner indicated that he reviewed the article: “Chronic prostatitis and erectile dysfunction: Results from a cross-sectional study.” Upon review of the article, the examiner stated that this study did not establish causation between erectile dysfunction and chronic prostatitis but discussed a higher incidence of erectile dysfunction in those who entered questions positive chronic prostatitis. The examiner opined that it does not establish that chronic prostatitis causes erectile dysfunction. More specifically, the examiner stated that the article submitted does not establish that chronic prostatitis causes erectile dysfunction, and there is an association between the two which is different than causation. The examiner opined that it is less likely than not the Veteran’s claimed erectile dysfunction was incurred in or caused by any in-service injury, event, injury or disease to include in service treatment for probable prostatitis. The examiner stated that the diagnosis of prostatitis was never confirmed and there was no indication that a recurrence took place or that a chronic condition developed. Additionally, the examiner stated that the records are silent after that date for any definitive prostate disease and there was no indication of prostate examination or antibiotic therapy for a probable prostatitis. Further, the examiner stated that the erectile dysfunction was not identified until many years after that date, and also there was intervening chemotherapy for his lymphoma at the time of onset. The examiner stated that the service treatment records are relatively silent with respect to any comment about erectile dysfunction until the recent compensation and pension examination. Although the Veteran had testicular pain and probable prostatitis during service, there are no clinical records reflecting complaints, diagnosis or findings related to ED problems until June 2012 (according to a private treatment record, when reported problems gaining erection since June 1998). Just as significant, ED occurred, at earliest, approximately 27 years after his military service ended. The United States Court of Appeals for the Federal Circuit has determined that such a lapse of time is a factor for consideration in deciding a service connection claim. Maxson v. Gober, 230 F.3rd. 1330, 1333 (Fed. Cir. 2000). Moreover, at that time, the Veteran did not attribute his erectile dysfunction to military service. Therefore, the preponderance of the evidence is against a finding as to the third element of the Holton analysis as it pertains to the requirement of a nexus or link between the current disability and an event, injury or disease in service. There also is no other competent and credible opinion in the file refuting the VA examiner’s unfavorable opinion. The Veteran’s statements are insufficient to rebut this opinion given the complexity of erectile dysfunction; he is not competent to comment on such matters. Just as importantly, there is no indication the Veteran had erectile problems to a compensable degree (meaning to at least 10-percent disabling) within this prescribed 1-year presumptive period following the conclusion of his service. 38C.F.R. §3.307 (a)(3), 3.309 (a). So, to this extent, it may not be presumed that an erectile dysfunction was incurred in service. The second question before the Board is whether the Veteran’s ED is caused or aggravated by a service-connected disability or treatment for such disability. As noted above, the Veteran also claims that his ED is related secondarily to non-Hodgkins lymphoma and/or any medications taken for his service-connected disabilities. Initially the Board notes that the Veteran’s claim for secondary service connection based on non-Hodgkins lymphoma fails, as service connection has been denied for this disability. The Veteran also claims that ED is caused by medication prescribed for service-connected disabilities. The Veteran is service connected for hearing loss and tinnitus. Significantly, however, he has not identified any medications that are taken for these disabilities and the medical record does not support this contention. Moreover, the Veteran has neither provided nor identified any competent evidence showing such a nexus. Therefore, the Board finds that the evidence weighs against a finding that this disability is caused or aggravated by previously service-connected disability. Therefore, the Board finds that the evidence weighs against a finding that this disability is caused or aggravated by previously service-connected disability. For these reasons and bases, the preponderance of the evidence is against the claim for service connection on a direct or secondary basis. Since the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Wilson, 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.