Citation Nr: 21015769 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 18-40 995 DATE: March 18, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to an initial 30 percent rating for peptic ulcer disease (PUD) with irritable bowel syndrome (IBS) is granted. REMANDED Entitlement to service connection for a prostate condition, to include as due to exposure to Agent Orange, is remanded. Entitlement to service connection for a disorder resulting in urinary incontinence is remanded. Entitlement to total disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The preponderance of the available and credible evidence is against finding that the Veteran’s bilateral hearing loss was incurred in or is attributable to active service. 2. The preponderance of the available and credible evidence is against finding that the Veteran’s tinnitus (unclear if unilateral or bilateral) was incurred in or is attributable to active service. 3. The Veteran’s PUD with IBS, where IBS is the predominant disability, manifests in alternating diarrhea and constipation with more or less constant abdominal distress. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2020). 2. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for an initial 30 percent rating for peptic ulcer disease (PUD) with irritable bowel syndrome (IBS) have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, Diagnostic Code (DC) 7304-7319. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from February 1964 to February 1966. His service included service in the Republic of Vietnam. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a July 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The claims were previously before the Board in November 2018, wherein they were remanded for additional development, including attempts to obtain private treatment records and providing additional VA examinations with opinions. A September 2020 rating decision granted entitlement to service connection for depressive disorder secondary to PUD. This is a full grant of the benefit on appeal related to the Veteran’s psychiatric claims, this part of the appeal is no longer before the Board. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim for a TDIU is part of an increased or initial rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Veteran and his representative have not expressly raised the issue of entitlement to TDIU. However, the Veteran has reported during ongoing psychiatric records that he changed jobs often and was not able to keep his job as mayor due to his psychiatric symptoms, particularly his reaction to people. He has also asserted that his psychiatric symptoms and PUD/IBS symptoms aggravate one another. As such, the Board finds that entitlement to TDIU has been reasonably raised by the record. Service Connection 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. § 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). 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 for certain diseases, such other organic diseases of the nervous system (hearing loss), may be also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). The Board notes however, that in this case, there is no medical evidence of record showing a diagnosis of hearing loss within one year of service, therefore, service connection on a presumptive basis would not be warranted. The Board must determine the value of all evidence submitted, including lay and medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. 1. Entitlement to service connection for bilateral hearing loss is denied. 2. Entitlement to service connection for tinnitus is denied. The Veteran argues that his current bilateral hearing loss and tinnitus are a result of his military service, specifically his service in the Republic of Vietnam for approximately six months. On his May 29, 2015 notice of disagreement, the Veteran wrote that “during those days” (referring to his 6 months in Vietnam) he was “losing [his] hearing and [he] had a horrible ringing in [his] ear that has never gone away. All caused by the [] explosions and rapid firing [he] was exposed to.” The Board notes that this statement indicated unilateral tinnitus. The Veteran also initially claimed entitlement to service connection for a right eardrum perforation which was not appealed. As noted in the 2018 Board remand, the Veteran’s duty MOS in service was as a supply handler/supply clerk. This MOS has a low probability of exposure to hazardous noise. However, the Veteran served for nearly six months in Cam Ranh Bay, Republic of Vietnam, and his representative has argued that he was exposed to hazardous noise during his service in Vietnam. Although his MOS remained as a supply clerk while in Vietnam, he stated that his duties included guard duty. Given the surroundings of his service in Vietnam, the Board conceded that he was exposed to hazardous noise during those six months. Turning to the available evidence of record, during his February 1966 separation medical history, the Veteran denied ear, nose, or throat trouble, and specifically denied ringing in his ears. He reported measles in May 1964, and mild colds, but otherwise his medical history was “essentially negative.” He wrote that he was in good health. The Veteran initially filed claims of entitlement to disability benefits in April 2013. His initial claim for benefits did not include a claim of entitlement to service connection for tinnitus or hearing loss, although he sought benefits for a number of other conditions. On June 1, 2015, the Veteran submitted claims of entitlement to service connection for tinnitus, bilateral hearing loss, and right ear condition. On July 20, 2015, the Veteran participated in a VA audiological evaluation in conjunction with his claims. The examiner noted that the Veteran had normal whisper hearing test results in January 1964 and February 1966. “The whisper speech test is not a frequency specific test.” The examiner noted that the whisper tests were not reliable. The July 2015 examination Puretone test results showed the Veteran had bilateral hearing loss for VA purposes. Following a review of the evidence, and interview and evaluation of the Veteran, the examiner provided a negative nexus opinion for the Veteran’s hearing loss. The examiner noted that there was no evidence found in the electronic record of complaints of hearing loss while in active service nor soon after release from active service. There was no evidence of any audiological treatment or care for hearing loss while in active service or soon after discharge. The United States Court of Appeals for Veterans Claims (Court) has held that service connection can be granted for hearing loss where the Veteran can establish a nexus between his current hearing loss and a disability or injury he suffered while he was in military service. Godfrey v. Derwinski, 2 Vet. App. 352, 356 (1992). The Court has also held that VA regulations do not preclude service connection for a hearing loss which first met VA’s definition of disability after service. Hensley, supra, at 159. In addition to the Veteran’s service treatment and post-service treatment records not showing complaints or treatment for hearing loss during service or within a few years after service, the examiner supported her negative opinion by noting that the Veteran had his first audiological follow-up 49 years after service at age 74. The examiner noted that, given the available evidence, the Veteran’s hearing loss could be due to the natural aging process, hereditary factors, and/or post-service noise exposure. Additionally, the examiner noted in the remarks section that the Veteran’s “voluntary responses were inconsistent and that he tended to exaggerate responses. He was re-instructed several times while testing.” Regarding his tinnitus, the Veteran reported to the examiner that he had a buzzing sound in both ears, but mainly in the left ear. “He could not specify a date or circumstances of onset.” The examiner noted his tinnitus was at least as likely as not caused by his hearing loss. The examiner noted that “considering all the above it [was her] opinion that the patient’s claimed hearing loss and tinnitus [were] less likely than not related ot his military service.” On March 27, 2017, the Veteran was seen by a VA physician for complaint of left ear fullness and was noted to have impacted cerumen. The Veteran reported he had a tympanic membrane perforation. “Refers has tinnitus know [sic] for years.” After his ear was cleaned, no perforation was seen; however, there was a scar on the tympanic membrane showing an old healed perforation. He was assessed with a history of tinnitus. An August 20, 2017 VA audiological general note included the Veteran’s report of bilateral hearing loss and tinnitus “for some time.” He was found to have hearing loss on testing. He received hearing aids from VA in October 2017. On July 17, 2018 the Veteran participated in another VA audiological examination. The examiner cited the 2015 and 2017 hearing evaluations and prior ENT (ear, nose, and throat) visits in March and July 2017. The ENT visits showed a scar from an old healed perforation of the tympanic membrane without current effusions, infection, or retraction. The Veteran reported the functional impact of his hearing loss was that he had to ask others to repeat themselves frequently, and his wife complained he watched television at too high of a volume. Regarding his tinnitus onset, the Veteran reported that it began “many years ago,” but he could not recall the circumstances of its onset. The examiner found that it was at least as likely as not his tinnitus was caused by his hearing loss. The Veteran reported that his right ear drum was perforated due to acoustic trauma while in service, and the examiner was asked to provide an opinion. The examiner provided a negative nexus opinion regarding a right ear condition, to include prior eardrum perforation. He noted that there was no medical note or other evidence regarding tympanic membrane perforation in the right ear. Otoscopic exam revealed right ear intact eardrum. The examiner noted that March and July 2017 ENT records showed a healed left tympanic membrane perforation in the left ear, but there were no prior notes on this matter. The Veteran did not report a history of ear bleeding or drainage, immediately after exposure to military noise, or at any time during active service. “Based on these facts, it is [the examiner’s] professional opinion that currently claimed left ear tympanic membrane perforation was less likely than not etiologically related to service.” The examiner noted that his tinnitus was bilateral, and therefore unlikely to be related to a tympanic membrane perforation. On his August 2018 substantive appeal, the Veteran requested service connection for hearing loss and tinnitus as “a result of [his] duties while in Vietnam.” On August 7, 2019, the Veteran was seen by his VA primary care physician for complaints of an itchy left ear. He had “a lot of cerumen and a little irritation” of the left ear. He was instructed to stop by audiology for “tinnitus problems lately.” Following the 2018 Board remand, the Veteran participated in a January 24, 2020 VA audiology examination. The examiner noted that audio evaluations from 2015 and 2018 showed mild to severe hearing loss. The 2020 Puretone threshold test again showed bilateral hearing loss. Notably, the Veteran’s word recognition score was 100 percent for both ears. The examiner provided a negative nexus opinion. At enlistment and separation test, the hearing tests were “whispered voice tests, which are not reliable tests to identify the presence of hearing loss that is typically found with military noise exposure.” The examiner again noted that there were no complaints of hearing loss or tinnitus in the claims file (lay or medical) for more than 40 years after service. Medical literature indicated that exposures to high intensity noise levels, like industrial/construction noise, printing work, music, or military noise, could cause permanent or progressive hearing loss during “prolonged periods of exposure. No retroactive hearing effects are expected after years of being exposed to high intensity noise. It is highly probable that VA evaluations show a bilateral hearing loss that is due to presbycusis or hearing loss expected as a normal aging process or a combination of both factors (aging process and noise exposure). It is reasonable to conclude that the bilateral hearing loss is less likely as not related to the military service.” Regarding his tinnitus, the Veteran was asked about the circumstances and onset of his tinnitus, and he replied that he had “intermittent tinnitus” for “many years.” He could not specify the circumstances of the onset of his tinnitus. The examiner found that the Veteran’s tinnitus was at least as likely as not due to his bilateral hearing loss, as tinnitus was known to be a symptom associated with hearing loss. The Board notes that the Veteran’s VA primary care physician treatment records include a summary of systems with options to select a variety of problems or to select “negative.” The summaries are based on the Veteran’s current complaints or ongoing treatment. The Veteran’s records from 2012 (earliest VA records available) to 2015 included only “negative” selections under the ENT section, wherein both tinnitus and hearing loss were options. Private records from prior to 2015 did not include complaint of or treatment for hearing loss or tinnitus. In adjudicating a claim, the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Board also has a duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Board acknowledges that the Veteran is competent to give evidence about what he experiences. See Layno v. Brown, 6 Vet. App. 465 (1994). Competency of evidence, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). See also Buchanan, supra (The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. If the Board concludes that the lay evidence presented by a veteran is credible and ultimately competent, the lack of contemporaneous medical evidence should not be an absolute bar to the veteran's ability to prove his claim of entitlement to disability benefits based on that competent lay evidence.) Here, the Veteran is competent to report when he first noticed hearing loss or tinnitus, particularly as tinnitus is a completely subjective condition. However, the Veteran’s 2015 statement that his hearing loss and tinnitus began in service and have continued to the present is considered less than credible when considering that the Veteran denied hearing loss and tinnitus on separation medical history, denied or did not report hearing loss or tinnitus to his primary care physician prior to 2015, did not file for hearing loss or tinnitus on his initial claim for disability benefits in 2013, and during his VA examinations he was unable to tell the examiners the onset or circumstances of his tinnitus/hearing problems. Taken together, the multiple VA examiners’ opinions establish that the Veteran’s hearing loss and tinnitus are not at least as likely as not related to an in-service injury, event, or disease, including his 6 months of exposure to hazardous noise. The VA examiners have opined that the Veteran’s hearing loss was likely age-related hearing loss, and that his tinnitus was due to his hearing loss. The combined rationale was that the Veteran was in his 70s when he initially sought treatment for and was diagnosed with hearing loss/tinnitus, and he had more than 40 years of post-service noise exposure. The examiners’ combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and consideration of the Veteran’s argument. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In sum, the Veteran has current bilateral hearing loss and tinnitus for VA purposes (current disabilities), and the Board has conceded that he was exposed to hazardous noise in service for approximately 6 months (in-service injury), but the preponderance of the evidence is against find that his current disabilities are due to his in-service injury. The Veteran denied hearing/ear problems and tinnitus on separation from service, he did not seek treatment or complain of hearing loss until 2015 (including not seeking benefits for hearing loss or tinnitus in 2013), he denied tinnitus and hearing loss problems with his primary care physician from the earliest 2012 record, has not provided credible/consistent statements regarding the onset of his symptoms, and the record contains multiple negative nexus opinions. The Board finds that entitlement to service connection for hearing loss and tinnitus are not warranted. Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be “staged.” Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service- connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). 3. Entitlement to an initial 30 percent rating for peptic ulcer disease (PUD) with irritable bowel syndrome (IBS) is granted. The Veteran is currently in receipt of a 10 percent rating for PUD with IBS. His treatment records also document gastritis. He argues that he warrants a rating in excess of 10 percent because his “stomach” is his “biggest problem.” The Veteran’s PUD with IBS is currently rated under diagnostic code 7319-7304. The Schedule of Ratings—Digestive System directs that ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive, will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflect the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants elevation. 38 C.F.R. § 4.114. Under DC 7804, a mild gastric ulcer with recurring symptoms once or twice yearly warrants a 10 percent rating. A moderate ulcer with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations warrants a 10 percent rating. A moderately severe ulcer, that is less than severe, but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year warrants a 40 percent rating. A severe ulcer, with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena with manifestations of anemia and weight loss productive of definite impairment in health warrants a 60 percent rating. Under DC 7319, mild IBS with disturbances of bowel function with occasional episodes of abdominal distress warrants a noncompensable rating. Moderate IBS with frequent episodes of bowel disturbance with abdominal distress warrants a 10 percent rating. Severe IBS with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress warrants a 30 percent rating. A July 8, 2010 endoscopy report noted that the Veteran had a small erosion at GEJ (gastroesophageal junction) with prominent prepyloric eroded folds. A biopsy was taken. The final impression was of erosive gastritis and reflux esophagitis. Omeprazole was prescribed. The gastric antrum biopsies showed chronic inactive gastritis. A November 1, 2010 record diagnosed acute diverticulosis. The handwriting was mostly illegible, but it was noted he had lower abdominal pain. A December 8, 2010 colonoscopy showed tiny diverticuli at the sigmoid without polyps or mucosa. Again, the handwriting was mostly illegible. The impression was of minimal diverticulosis coli. In July 2015, the Veteran participated in intestinal and stomach/duodenal VA examinations. The intestinal examination showed that the Veteran had a diagnosis of IBS from 1964. He reported symptoms of stomach discomfort, nausea, diarrhea, and constipation since 1964. He used Zantac and Pepto-Bismol for symptoms with “fair response.” The examiner incorrectly believed that his last colonoscopy was in 2003, with normal findings. The examiner also did not have a copy of the endoscopy report, and erroneously believed he had not had one before. The examiner found that continuous medication was not required for control of the Veteran’s IBS, and he had not undergone surgical treatment for his IBS. Symptoms associated with his IBS included constipation and then diarrhea with some meals. The examiner selected that the Veteran did not have abdominal distress or exacerbations or attacks of the intestinal condition. He did not have weight loss, malnutrition, serious complications or general health effects attributable to his IBS. The examiner noted his IBS would not impact his ability to work. The July 2015 Stomach and Duodenal VA examination included that the Veteran had a diagnosis of PUD from 2005. He took continuous medication for his peptic ulcer (Zantac). He had recurrent episodes of symptoms that were not severe. He had four or more episodes per year of less than one day duration. He had periodic abdominal pain, and mild nausea four or more times per year, lasting less than one day. He did not have any incapacitating episodes of PUD. An August 24, 2015 record included the Veteran’s report of epigastric pain for the past several months. He had a history of PUD without treatment. He was to be started on Pantoprazole and Ranitidine. On evaluation he had mild epigastric tenderness to palpation with no other abnormal findings. On December 10, 2015, the Veteran was seen in the VA emergency department (ED) for epigastric pain. He was given a Famotidine IV and his pain resolved. On follow-up evaluation on December 28, 2015, he complained of ongoing mild epigastric discomfort. He had signs and symptoms of dyspepsia and the physician noted that they may be medication-induced (Sertraline) v. GERD v. PUD. A May 28, 2016 VA primary care record included the Veteran’s report of mild epigastric discomfort. He described it as continuing to have “daily abdominal discomfort.” He was prescribed Pantoprazole and Ranitidine, but had not been compliant with the latter medication. On evaluation, he had mild epigastric discomfort, but no “signs or alarming symptoms.” On June 10, 2016, the Veteran had a VA gastrointestinal consultation wherein he reported “persistent epigastric pain, refractory to PPIs.” He reported more than 30 years of chronic abdominal discomfort, worse over the epigastric area. He denied current constipation, change in bowel habit, weight loss, anorexia, melena, or hematochezia. On physical evaluation, he did not have tenderness to palpation or guarding of the abdomen. His labs were unremarkable. He was noted to have a history of PUD, “currently responsive to H2 blockers. Not using PPI due to side effect of dizziness.” By November 7, 2016, the Veteran continued to report daily abdominal discomfort. By this time, he was compliant with his medications, but continued to have mild epigastric discomfort on examination. He had a bout of viral enteritis in March 2017. A June 12, 2017 VA gastrointestinal consultation included the Veteran’s report of intermittent episodes of constipation alternated with diarrhea. He described his constipation as “sometimes so severe he had to manipulate himself to be able to have a bowel movement, other times stools are loose.” He also reported epigastric burning pain along with lower abdominal burning sensation, somewhat improved after meals. He reported using Zantac occasionally. He denied unintentional weight loss, loss of appetite, fever, chills, or blood in his stools. Physical examination was remarkable for epigastric and lower abdominal discomfort to palpation. He had findings “concerning for GERD/gastritis.” There was no evidence of EGD (esophagogastroduodenoscopy) on record, and he denied EGD in the past. His symptoms and clinic picture indicated gastritis. An August 11, 2017 upper endoscopy, provided due to his complaints of GERD, included finding of salmon-colored mucosa at 35 cm. He was assessed with rule out Barrett’s esophagus. During a March 6, 2018 primary care record the Veteran reported intermittent abdominal pain for a long time. He stated he was an anxious person, and had chronic problems with constipation which turned into diarrheas after a bowel movement. He was assessed with gastritis and started on a trial of Omeprazole. Physical examination did not show guarding, rebound pain, acute pain, or pain to palpation. His lower quadrant pain was noted to be “subjective, but no evidence in physical exam of an acute abdominal pain.” The Veteran denied nausea and vomiting. “Insidious pain that seems to be associated to his anxiety and somatization.” He was offered to be transferred to the emergency department to do an abdominal CT, but he refused. A March 26, 2018 private record from Dr. J.HR included the Veteran’s complaint of “diverticular-type pain.” A CT scan was ordered. The April 11, 2018 CT scan showed a large prostate, thickened bladder walls, two small diverticula on the lateral walls of the bladder, and degenerative changes of the spine. An April 25, 2018 record included a “current diagnosis” section with the following: gastritis without bleeding (April 25, 2018), bacterial meningitis (April 25, 2018), diverticulosis of large intestine without perforation, abcess, or bleeding (March 26, 2018), and left lower quadrant pain (March 26, 2018). On May 9, 2018, the Veteran returned to the VA gastrointestinal consultations for “severe constipation and with a non-specific lower abdominal pain, that is an insidious pain.” He denied rectal bleeding. His last colonoscopy, six years prior, found “small polyps.” He reported bouts of diarrhea and constipation and occasional thin stools. “Given the above history and results, [the veteran] most likely presenting from IBS.” As the Veteran had glaucoma, anti-spasmodics were contraindicated. A May 14, 2018 VA primary care record noted the Veteran’s medical history as including chronic dyspepsia/history of PUD. The Veteran complained of heartburn, but reported some improvement in epigastric discomfort. He had prescriptions for Omeprazole and Simethicone. He did not have tenderness to deep palpation of epigastric region. “Patient still refers symptoms but says he ran out of medication several months ago and did not request refills.” On July 6, 2018, the Veteran participated in additional IBS and stomach/duodenal examinations. On his IBS examination, he reported continued intestinal pains, nauseas, and constipation (with “pencil-like stools”) alternated with diarrheas. He stated that his symptoms disturbed him from enjoying life because they were unremitting. He had a private gastroenterologist, who scheduled a colonoscopy for the end of the month (July 2018). He was on continuous medication for the control of his IBS. He had alternating diarrhea and constipation, nausea, and intestinal pains listed as his IBS symptoms. The examiner selected that the veteran had more or less constant bowel disturbance with abdominal distress. He did not have weight loss attributable to his intestinal condition. He did not have malnutrition, serious complications or other general health effects attributable to his IBS. During his Stomach and Duodenal examination, the Veteran was diagnosed with PUD, and he reported symptoms of continued pain in the stomach and intestines, accompanied by nausea, acidity, and reflux. He stated the symptoms were daily (he did not have a day when he does not have these symptoms). He had an endoscopy in August 2017, which showed a normal stomach and normal duodenum, without ulcer. He was on continuous medication for his ulcer and IBS (Pantoprazole and Ranitidine). He was noted to have recurring episodes of symptoms that were not severe 4 or more times per year. He had abdominal pain at least monthly, that was pronounced, continuous, and unrelieved by standard ulcer therapy. He had recurrent nausea, with average duration of less than one day. A private July 26, 2018 colonoscopy showed mild diverticulosis coli and internal hemorrhoids. A September 10, 2018 VA primary care record noted the Veteran’s report of 20 years of abdominal pain that was exacerbated by eating. He also complained of constipation followed by diarrhea, with bowel movements alleviating pain. On January 19, 2019, the Veteran sought treatment in the VA ED for abdominal pain for two days with loss of appetite. He denied fever, chills, nausea, or vomiting. He reported 2 episodes of paste-like diarrheas. He noted he had several similar symptoms in the past due to a long history of PUD and diverticulosis. The working diagnosis was diverticulitis v. gastroenteritis. A CT scan showed moderately thickened sigmoid colon with moderate diverticulosis without surrounding mesenteric fat inflammatory change. The findings “favor sequelae of chronic diverticulitis.” October 2019 and January 2020 VA primary care records noted that the Veteran’s IBS-flares may be associated with episodes of stress. Given the above evidence, the Board will resolve reasonable doubt in the Veteran’s favor that his PUD with IBS more closely approximated severe IBS during the entire period on appeal. The July 2018 IBS examiner noted that the Veteran had more or less constant bowel disturbance with abdominal distress. This finding is consistent with his ongoing VA and private treatment records, as the Veteran’s main complaint to physicians over the years was either psychiatric or abdominal/epigastric discomfort, pain, diarrhea, and constipation. Given the Veteran’s overall complaints, and the more objective findings on colonoscopy v. endoscopy, the Veteran’s predominant disability is his IBS. With the finding that the Veteran’s IBS is severe, he warrants a 30 percent rating under DC 7319, for the entire period on appeal. The Board has considered if an evaluation in excess of 30 percent is available/warranted and finds that there is not. The Veteran does not meet the criteria for moderately severe or severe gastric ulcer (40 and 60 percent, respectively). The record does not show findings such as impairment of health manifested by anemia and weight loss, recurrent hematemesis or melena, or incapacitating episodes averaging 10 days per episode and occurring four or more times per year. The Board also considered other digestive system diagnostic codes, but found that the other ratings were either not applicable or would not warrant in a rating in excess of 30 percent. REASONS FOR REMAND 1. Entitlement to service connection for a prostate condition, to include as due to exposure to Agent Orange, is remanded. 2. Entitlement to service connection for a disorder resulting in urinary incontinence is remanded. The Veteran’s claims for entitlement to service connection for a prostate condition and urinary incontinence must be remanded for an addendum opinion. The Veteran has service in the Republic of Vietnam, and has argued that he developed his prostate condition as a result of exposure to Agent Orange. His urinary incontinence is intertwined with his claim for a prostate condition. The Veteran participated in VA prostate cancer and urinary condition examinations in January 2020. The examiner opined that the Veteran’s urinary incomitance was due to his benign prostate hypertrophy (BPH). The examiner provided a negative nexus opinion for prostate cancer and BPH. The Veteran’s BPH had onset many years after active service and the etiology was “hereditary factors and related to age. The VA has not found that a positive association exists between BPH and Agent Orange exposure.” Additionally, the examiner noted that there was no evidence of bladder or urethral conditions during examination. The Veteran’s urinary incontinence was “urge incontinence secondary to” BPH. The examiner noted that the Veteran’s service treatment records and VA treatment records did not show signs, symptoms, complaints, diagnosis, treatments or any chronic disability pattern regarding BPH or other prostate condition during active military service or within a year after separation from service.” Again, the examiner noted that VA had “not found that there was a positive association between BPH and Agent Orange exposure.” The Board must remand for an opinion that addresses whether the Veteran’s BPH was caused by his exposure to Agent Orange. Although the January 2020 addressed the Agent Orange contention, the opinion provided was that VA had not provided a presumptive service-connection association between BPH and exposure to Agent Orange. In other words, there is not a legal association between BPH and exposure to Agent Orange. However, direct service connection remains available to the Veteran if evidence supports a connection between BPH and exposure to Agent Orange. As such, the Board needs a nexus opinion based on medical findings/knowledge/treatises. 3. Entitlement to total disability based on individual unemployability (TDIU) is remanded. The issue of TDIU is addressed as reasonably raised by the record. The record does not contain a current TDIU claim form, which would contain pertinent information about prior employment, education and training. On remand, the Veteran should be asked to complete a TDIU claim form. The matters are REMANDED for the following action: 1. Provide the Veteran with a copy of a VA TDIU claim form and request that he complete and return the form. 2. Return the case to the January 2020 prostate/urinary examiner, if available, for an addendum opinion. Is it at least as likely as not (50/50 probability or greater) that the Veteran’s BPH is due to his exposure to Agent Orange in Vietnam? Although BPH is not a presumptive service-connected condition due to Agent Orange exposure, the Veteran has argued that his BPH is due to Agent Orange exposure. The examiner’s opinion must be based medical knowledge, treatises, records. A complete rationale must accompany each opinion expressed. 3. After completing the development requested above, readjudicate the Veteran’s claims. If any of the benefits sought are not granted in full, the Veteran and his representative should be furnished a Supplemental Statement of the Case and given the opportunity to respond thereto. The case should then be returned to the Board, if otherwise in order KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. H. Stubbs, 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.