Citation Nr: 21024576 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 11-23 783A DATE: April 23, 2021 ORDER Entitlement to service connection for hypogonadism with erectile dysfunction is granted. REMANDED Entitlement to service connection for hypertension, to include as due to herbicides and/or as secondary to service-connected posttraumatic stress disorder (PTSD) or diabetes mellitus is remanded. FINDING OF FACT Erectile dysfunction is associated with hypogonadism and symptoms of erectile dysfunction began during the Veteran’s period of active duty and persisted since that time. CONCLUSION OF LAW The criteria for entitlement to service connection for erectile dysfunction have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty in the U.S. Army from October 1968 to January 1972 and from January 1978 to July 1991, with service in the Republic of Vietnam from April 1969 to October 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a June 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2017 the Veteran testified at a Board hearing before the undersigned Veterans Law Judge, and a transcript of the proceeding is of record. The matter was remanded in September 2018 and September 2019, and has been returned for further appellate review. 1. Entitlement to service connection for erectile dysfunction to include as due to herbicides and/or as secondary to service-connected posttraumatic stress disorder or diabetes mellitus is granted. 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, 1131 (2012); 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran 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 - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially 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). In addition, service connection for certain chronic diseases, including endocrinopathies (such as hypogonadism), may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 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 (2017); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310 (2018); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran alleges that he first experienced erectile dysfunction in service and that it has persisted since that time, and alternatively, that erectile dysfunction may be caused or aggravated by service-connected PTSD or diabetes mellitus. See February 2009 notice of disagreement; see April 2011 VA examination report (noting the Veteran’s reported 20-year history of erectile dysfunction). First, erectile dysfunction has been diagnosed during the appeal period. See September 2007 private treatment record; see April 2011 VA examination. Thus, there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). Second, the preponderance of the evidence shows symptoms of erectile dysfunction first began in service. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). Here, the Veteran has testified that he began to experience symptoms of erectile dysfunction in service but did not seek treatment or mention the issue out of embarrassment. See April 2011 VA examination report; see March 2019 hearing testimony. The Veteran’s wife also provided similar supporting testimony at the Board hearing. The Veteran is competent to report symptoms he experienced, and his wife is competent to report things she observed. VA treatment records note that the Veteran was treated with testosterone shots in 1995, around 4 years after separation from service, which is consistent with the lay testimony of in-service onset and gradual progression. The Board has already found as adequate an August 2019 VA examiner’s conclusion that erectile dysfunction was not caused by diabetes mellitus. See September 2019 Remand. That examiner based their conclusion in reliance upon the Veteran’s testimony of erectile dysfunction symptoms since 1991. Later, an October 2020 VA examiner opined that erectile dysfunction did not manifest in service because there was no objective evidence of the condition in service. The 2020 examiner’s conclusion is outweighed by the competent and credible lay testimony and the evidence of testosterone treatment as early as 1995. Third, the Board finds that the evidence of record does support a finding that the erectile dysfunction is etiologically related to active service. It is at least as likely as not that erectile dysfunction had onset during the Veteran’s period of service and has persisted unabated since that time. The August 2019 VA examiner documented that erectile dysfunction symptoms began around 1991 and gradually worsened over time, leading to treatment with testosterone and eventual complete erectile dysfunction. The 2019 examiner also found that the erectile dysfunction was a manifestation of hypogonadism, which is a chronic disease. Though the Veteran did not specifically claim entitlement to service connection for hypogonadism, the erectile dysfunction is a symptom associated with the condition and the Veteran is presumed to seek entitlement to service connection for the underlying condition. The testosterone therapy was initiated in March 1995 within 4 years after separation from service. Despite the lack of objective evidence of erectile dysfunction in service, in light of the consistent medical and lay evidence of gradually worsening symptoms since an in-service onset, the evidence is in relative equipoise and reasonable doubt is resolved in the Veteran’s favor. Accordingly, presumptive service connection is granted for hypogonadism with erectile dysfunction. REASONS FOR REMAND 1. Entitlement to service connection for hypertension, to include as due to herbicides and/or as secondary to service-connected posttraumatic stress disorder or diabetes mellitus is remanded. First, this issue is remanded to obtain outstanding and relevant federal treatment records. Available Montgomery VA Medical Center (VAMC) records include the Veteran’s medication history and document the Veteran was prescribed atenolol and lisinopril in November 1994 at the Lyster Army Health Clinic at Fort Rucker. VA examiners have explained that atenolol and lisinopril are prescribed to treat the Veteran’s hypertension. See February 2008 VA examination; see August 2019 VA exam. Review of the record does not show any treatment records from the Lyster Army Health Clinic. These records are relevant because the onset of hypertension is in question. Thus, remand is required to obtain them. Second, remand is necessary for an addendum opinion addressing whether hypertension is caused or aggravated by the Veteran’s conceded in-service exposure to Agent Orange. A 2018 National Academy of Sciences (NAS)/Institute of Medicine (IOM), Veterans and Agent Orange report update has been released that now shows hypertension was upgraded from its previous classification in the category of “limited or suggestive” evidence of an association to the category of “sufficient” evidence of an association. According to NAS, “[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association” between hypertension and herbicide exposure. In light of the new study, an addendum opinion is required as to whether hypertension is at least as likely as not caused or aggravated by exposure to Agent Orange despite not being listed among the presumptive conditions. Remand is also necessary for an addendum on whether it is at least as likely as not that hypertension manifested to a compensable degree within one year of separation from service in light of the evidence that the Veteran was prescribed medication for hypertension within 4 years of separation from service. Previously, VA examiners have reported that the Veteran did not begin to take medication for hypertension until the late 1990s. Last, on remand efforts must be made to identify and obtain outstanding and relevant VA or private treatment records. 38 C.F.R. § 3.159(c)(1); Dunn v. West, 11 Vet. App. 462 (1998); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain all outstanding records from Lyster ACH Fort Rucker since 1994. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 3. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 4. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the hypertension from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that hypertension is caused by in-service exposure to Agent Orange. (b.) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that hypertension manifested within one year of separation from service. (c.) The examiner must address the following: 1) Montgomery VAMC prescription list documenting the Veteran was prescribed atenolol and lisinopril as early as December 1994; 2) the 2018 NAS update concluding that there is a positive association between hypertension and herbicide exposure; 3) the STRs showing multiple elevated blood pressure readings in service and an assessment of borderline hypertension shortly before separation from service; 4) the August 2019 VA examination report documenting the Veteran’s report of lightheadedness since approximately 1986. K. MILLIKAN Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Smith, 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.