Citation Nr: 21015367 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 10-25 219 DATE: March 17, 2021 ORDER Entitlement to service connection for a urinary tract disorder (to include chronic bladder condition, kidney stones, and urinary frequency) is denied. FINDING OF FACT The Veteran’s urinary tract disorder, to include chronic bladder condition, kidney stones, and urinary frequency, is not etiologically related to service, and did not manifest within one year of separation from service. CONCLUSION OF LAW The criteria for entitlement to service connection for a urinary tract disorder (to include a chronic bladder condition, kidney stones, and urinary frequency) have not been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty from July 2000 to July 2003 and from September 2005 to December 2006, to include service in Southwest Asia. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2007 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). By way of history, the Veteran filed an original claim for service connection for a bladder condition in November 2006. The Agency of Original Jurisdiction (AOJ) denied his claim in the December 2007 rating decision on appeal. The Veteran subsequently filed a notice of disagreement (NOD) in March 2008 and appealed this matter to the Board. The Board has since remanded this claim on numerous occasions: in June 2015, July 2016, March 2017, June 2018, and most recently, in August 2020. Each time the Board has remanded this claim to the AOJ for further evidentiary development. In August 2020, such development included obtaining relevant federal medical records as well as medical opinions for adjudication of the Veteran’s claim. In consideration of this appeal, the Board finds that there has been substantial compliance with the Board’s August 2020 remand directives and will proceed with appellate review. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Entitlement to service connection for a urinary tract disorder (to include chronic bladder condition, kidney stones, and urinary frequency) is denied. The Veteran contends his current urinary tract disability is related to his active duty service. Specifically, the Veteran asserts that he suffered from kidney stones and other bladder issues during active duty and that such symptoms have persisted since. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence including that pertinent to service, establishes the disability was incurred in service. 38 C.F.R. § 3.303(d). For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Notable for this case, kidney stones (calculi of the kidney) are considered to be a chronic disease for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Turning to the evidence of record, the Veteran has a current diagnosis of nephrolithiasis (kidney stones), as well as urinary frequency (categorized as a bladder condition). See e.g., October 2020 VA examination. Thus, the first element of service connection has been met. The Veteran’s service treatment records (STRs) contain some notations indicating that the Veteran sought acute medical care for lower right abdominal pain but no accompanying incontinence. See e.g., June 9, 2003 note. Further, a urinalysis was performed concurrently and was negative for any abnormalities. Significantly, as discussed in further detail below, the Veteran contends that at this same time during his active duty service he suffered from a kidney stone and sought treatment from a medical provider outside of the military. VA treatment records following separation from service reflect that the Veteran underwent an abdomen ultrasound exam in April 2015, which indicated that his “kidneys are normal in size and echotexture[.] There is no hydronephrosis, renal calculus, or perinephric fluid. No definite solid renal masses are seen.” See April 28, 2015 ultrasound report. The Veteran was afforded a VA examination for urinary tract and bladder conditions in September 2015. The VA examiner diagnosed the Veteran with renal lithiasis (kidney stones) and urinary frequency. The Veteran indicated that he “has to urinate more frequently now.” The Veteran reported that while he was in service, in 2003, he sought treatment from an outside medical provider at a hospital for a kidney stone. Since then, the Veteran reported he has not had a reoccurrence of his renal lithiasis. The VA examiner noted that the Veteran has a voiding dysfunction, causing increased urinary frequency, with his daytime voiding interval less than one hour. The VA examiner also indicated that the Veteran’s voiding dysfunction caused signs or symptoms of obstructed voiding, including weak stream and decreased force of stream. Regarding etiology, the September 2015 VA examiner indicated that the Veteran’s urinary tract condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner reasoned that the Veteran’s “STRs dated 06/09/2003 show complaints of severe right lower quadrant abdominal pain, however, the urinalysis was negative. Medical records from the outside provider in 2003 are not located. Based on the medical records available for review, and the single episode by history of renal lithiasis, an opinion cannot be provided without resorting to mere speculation. Additional information (medical records from the outside provider in 2003) is required.” Subsequent VA treatment records reflect the Veteran continued to report abdominal pain, as well as increased urinary frequency, and pain or burning during urination. See e.g., July 3, 2016 note; July 6, 2016 note. Private treatment records submitted by the Veteran reflect that he sought treatment for his lower abdominal pain outside the VA. His private treatment provider performed a CT scan of his abdomen and found a kidney stone in 2015. See e.g., December 2015 private treatment note. Pursuant to the July 2016 remand directives, an addendum medical opinion was obtained in September 2016. The September 2016 VA examiner opined that the Veteran’s current urinary tract condition was less likely than not incurred in or caused by an in-service event, injury, or illness. The VA examiner stated that “[t]here is insufficient medical evidence within the medical records to support the claim of a bladder disability/urinary frequency. Therefore, a clinical diagnosis of bladder condition/urinary frequency cannot be endorsed at this time.” The Board remanded the claim again in June 2018, finding that the September 2016 addendum medical opinion was inadequate. As such, the Veteran underwent an additional VA examination for urinary tract and kidney conditions in August 2019. The August 2019 VA examiner diagnosed the Veteran with renal calculi (kidney stones). The Veteran reported again that in 2003 he had urinary signs and symptoms and was diagnosed with his first kidney stone by an outside provider during service. The Veteran indicated that he has experienced repeat episodes of kidney stones on and off since then and continues to experience urinary signs and symptoms, such as urinary frequency. The VA examiner noted that the Veteran has not had treatment for recurrent stone formation. The VA examiner indicated that the Veteran has signs or symptoms associated with urolithiasis, including voiding dysfunction. On the urinary tract conditions examination, the VA examiner diagnosed the Veteran with urinary frequency. The VA examiner noted that the Veteran’s symptoms included hesitancy, slow stream, weak stream, and decreased force of stream. The VA examiner opined that the Veteran’s condition was less likely than not incurred in or caused by an event, injury, or illness in service. The VA examiner indicated that “[t]here are many conditions that result in urinary frequency, and it is my belief that when [the Veteran was] diagnosed with urinary frequency, it was a result of an indeterminate cause intended to be worked up as it is usually a symptom of an underlying disease process or condition.” Regarding the Veteran’s claimed kidney stones, the VA examiner indicated that “there are no records of official diagnosis confirming (the 2003 treatment by outside provider). While the Veteran mentions he continues to have signs and symptoms of renal stones, it cannot be concluded that he has chronic kidney stones as there is no prior evidence producible by the STRs, and it is recommended that a lay statement be confirmed with imaging or diagnostics for such a condition. All of which have been done in the past and have been unremarkable for renal stones[.]” The Veteran also submitted a lay statement from a fellow servicemember in support of his claim in August 2020. The fellow servicemember, E.M., indicated that he had served with the Veteran from August 2000 to August 2003 in the same unit. E. M. reported that during their leave time in approximately June 2003, he and the Veteran took a road trip. During the drive, the Veteran purportedly complained about “lower back and stomach pains[.]” The servicemember reported that the Veteran thought the pain would go away, but as they continued to drive it only worsened. E. M. relates that eventually, the Veteran’s pain was so severe that he was forced to “pull over at a medical clinic [or] facility in a small town” and he went in for treatment. However, E. M. stated that “I don’t recall what medicines they gave him, and I have no recollection of what they did for him inside the medical facility and I have no recollection of what the problem actually was. At the time I could only assume what the issues might have been stomach, back, kidney problems, etc.” See August 2020 buddy / lay statement. The Veteran was afforded an additional VA examination in October 2020. The VA examiner first completed a kidney conditions DBQ. The VA examiner confirmed the Veteran’s diagnosis as nephrolithiasis (kidney stones). Regarding this condition, the Veteran reported that the condition began in 2003 with back and abdominal pain, as well as feeling like he was urinating “little pieces of rocks[.]” The Veteran reported that he currently experiences “constant use of the bathroom, feeling of not emptying his bladder fully, and needing to use the bathroom 4-6 times per night.” The VA examiner indicated that the Veteran had experienced kidney calculi previously, for which the Veteran underwent drug therapy. The urinary tract DBQ indicates that the Veteran still suffers from urinary frequency. Regarding etiology of the Veteran’s urinary tract condition, the October 2020 VA examiner opined that the claimed condition was less likely than not incurred in or caused by the Veteran’s active service. The VA examiner stated that “the Veteran was seen in service on June 9, 2003 for lower abdominal pain. He was seen in the ER, showed nontender abdomen, and no urinary symptoms were present. No further follow up in service. [The Veteran] was also seen in 2009 for similar symptoms. KUB was negative for kidney stone. No definite history of kidney condition. Based on the documentation available, his current kidney stone condition is less likely than not due to service.” Regarding the Veteran’s urinary frequency, the VA examiner also opined that it is less likely than not related to his military service, indicating that “there is no documentation of urethral injury or bladder injury in service. However, KUB x-ray in 2009 and abdominal CT in 2015 has been normal, without evidence of calculi. Per VA primary care provider note in February 2020, [the Veteran] reported no problems with kidney stones. Current urinalysis is normal.” The VA examiner also provided an opinion addressing secondary service connection, in response to the assertion that the Veteran’s current urinary tract condition is caused by or aggravated by the Veteran’s service connected back condition. The VA examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran’s service-connected back condition as “today, the Veteran denies any symptom of saddle anesthesia, he is able to initiate urination, and has now bowel symptoms. Recent primary care notes in 2020 does not document aggravation of back pain or any other symptoms of (spinal) cord compression. Due to the absence of documentation of nerve root or cord compression and in the absence of documentation of neurogenic bladder, his current bladder symptoms are less likely due to back condition.” The Board concludes that, while the record demonstrates a urinary tract condition, including a diagnosis of kidney stones and urinary frequency, these conditions did not manifest to a compensable degree in service or within an applicable presumptive period, and continuity of symptomatology is not established. The record does not otherwise establish a relationship between such conditions, including kidney stones, and service. Multiple VA examiners of record opined that there is no relationship between the Veteran’s current urinary tract symptoms and his active duty service. More significantly, the October 2020 VA examiner, who thoroughly reviewed the Veteran's claims file, took a complete history from the Veteran, and clinically examined the Veteran, opined that it is less likely than not that the Veteran's urinary frequency was incurred in or caused by the active duty service, to include as secondary to his service-connected lumbar spine disability. The October 2020 VA examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). To the extent that the Veteran asserts that kidney stones and his urinary frequency are related to service, the Board observes that he may attest to factual matters of which he has first-hand knowledge, such as subjective complaints, and that his assertions in that regard are entitled to some probative weight. He is competent to report incidents and symptoms in service and symptoms since then. He is not, however, competent to render an opinion as to the cause or etiology of the current diagnosis because he does not have the requisite medical knowledge or training, and because this matter is beyond the ability of a lay person to observe. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007) The grant of service connection requires competent evidence to establish a diagnosis and, as in this case, relate the diagnosis to the Veteran's service. While the record indicates a history of kidney stones and urinary frequency, it does not contain reliable evidence which relates this claimed disability to any incident of service. For these reasons, the Board concludes that the claim of entitlement to service connection for a urinary tract condition, to include urinary frequency and kidney stones, must be denied as the preponderance of the evidence is against the claim. The doctrine of reasonable doubt is not applicable in the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. M. Lowman, 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.