Citation Nr: 21025563 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 15-01 027 DATE: April 28, 2021 ORDER Entitlement to an initial disability rating of 20 percent, but no higher, for erectile dysfunction is granted. Entitlement to a rating in excess of 60 percent disabling for prostate cancer is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is denied. REFERRED The issue of entitlement to service connection for a low back disability was raised in a March 2021 statement and is referred to the Agency of Original Jurisdiction (AOJ) for adjudication. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran has a penis deformity with loss of erectile power. 2. The evidence does not show that the Veteran has renal dysfunction. 3. The Veteran’s prostate cancer is primarily manifested by voiding dysfunction; he has been in receipt of the highest schedular rating available based on voiding dysfunction throughout the relevant period. 4. The preponderance of the evidence is against finding that the Veteran’s service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability rating of 20 percent, but no higher, for erectile dysfunction have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.115b, Diagnostic Code 7522. 2. The criteria for entitlement to an evaluation in excess of 60 percent disabling for prostate cancer have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.115b, Diagnostic code 7528. 3. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from January 1968 to December 1969, to include service in the Republic of Vietnam. This matter comes to the Board of Veterans' Appeals (Board) on appeal from March and November 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The matters were remanded in December 2018 and again in November 2020 for further development, including affording the Veteran VA examinations in order to assess the current severity of the disabilities at issue on appeal, obtaining private treatment records, and providing the Veteran the opportunity to complete a VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability, for substantiation of a claim of entitlement to a TDIU. See December 2018 and November 2020 Board Decisions. The matters are now returned to the Board for further consideration. Duty to Notify and Assist Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). VA has satisfied its duties to inform the Veteran of evidence needed to substantiate the claim. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 21.1032. In April 2019, a Notice was provided to the Veteran with information regarding: compensation at the 100 percent rate due to unemployability, the provision or identification of treatment records, and evidence in the form of lay statements, along with VA Forms 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability; VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits; VA Form 21-4138, Statement in Support of Claim; VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs; VA Form 21-4142a, General Release for Medical Provider Information; and a 38 U.S.C. § 5103 Notice Response. See April 2019 VA Custom 5103 Notice. VA has satisfied its duties to assist the Veteran with obtaining evidence to substantiate the claim. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 21.1032(a). VA examinations were performed, medical opinions were obtained, and records relevant to the claim were received. Pursuant to the December 2018 and November 2020 Board remands, VA medical opinions were provided to assess the severity of the Veteran’s service-connected disabilities and to determine which disabilities impacted the ability of the Veteran to work. See December 2018 and November 2020 Board Decisions. The entire record was available to the January 2013, February 2020, and January 2021 examiners. See January 2013, February 2020, and January 2021 VA examination reports. The examinations were adequate to address all potential rating criteria, allowing for an informed decision on the matters in the claim. See 38 C.F.R. §§ 4.14, 4.40, 4.59, 4.104. The Board finds that the RO’s efforts have substantially complied with the instructions contained in the December 2018 and November 2020 Board remands. See Stegall v. West, 11 Vet. App. 268 (1998). Further, the Board acknowledges that VA has done everything necessary under 38 C.F.R. § 21.1032(a) to assist the Veteran. 1. Entitlement to a compensable initial rating erectile dysfunction The Veteran is seeking an increase in his initial disability rating for his service-connected erectile dysfunction, which is currently evaluated as a noncompensable schedular rating. See March 2013 VA Rating Decision Narrative. Disability evaluations are determined by the application of facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) in 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred in or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. It is necessary to evaluate the disability in light of the whole recorded history, reconciling any examination reports into a consistent picture so that the current rating accurately reflects the symptoms of the present disability. Each disability must be considered from the point of view of the Veteran working or seeking work, adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1, 4.2. In considering the severity of a disability, it is essential to trace the medical-industrial history of the disabled person from the original injury, considering the nature of the injury and the attendant circumstances, and the requirements for, and the effect of, treatment over past periods, and the course of recovery to date. The duration of the initial, and any subsequent, period of total incapacity, especially periods reflecting delayed union, inflammation, swelling, drainage, or operative intervention, should be given close attention. This consideration, or the absence of clear-cut evidence of injury, may result in classifying the disability as not of traumatic origin, either reflecting congenital or developmental etiology, or the effects of a healed disease. 38 C.F.R. § 4.41. Where there is a question as to which of two evaluations will be applied to a disability, the higher evaluation will be assigned, if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Once entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). Separate, staged ratings can be assigned for new or separate evaluations as changes in symptoms are applied to the established rating criteria. In the case of initial ratings, the period for consideration begins with the effective date of service connection. Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35 (1993) (holding that a claim for an original or increased rating remains in controversy when less than the maximum available benefit is awarded). There is no diagnostic code which addresses erectile dysfunction exclusively. The Veteran’s erectile dysfunction is currently evaluated under 38 C.F.R. § 4.115b, Diagnostic Code 7522, which pertains to deformity of the penis with loss of erectile power. Diagnostic Code 7522 is deemed by the Board to be the most appropriate disability evaluation because it is the only diagnostic code that addresses loss of erectile power among its rating criteria. The Board can identify nothing in the evidence to suggest that an alternative diagnostic code would more nearly approximate the symptoms of the Veteran’s penis deformity. Under Diagnostic Code 7522, a rating of 20 percent is warranted when there is deformity of the penis with loss of erectile power. Under Diagnostic Code 7522, 20 percent is the highest schedular evaluation allowed. See 38 C.F.R. § 4.115b. Turning to the evidence of record, in the March 2013 rating decision, the Veteran was granted service connection for erectile dysfunction secondary to his service-connected prostate cancer and assigned a noncompensable initial rating under Diagnostic Code 7522. He was also granted SMC under 38 U.S.C. § 1114(k) for loss of use of a creative organ. See March 2013VA Rating Decision Narrative. The Veteran filed a timely appeal. See VA Form 21-0958, Notice of Disagreement. Pursuant to the December 2018 Board remand, the Veteran took part in a VA Male Reproductive System Conditions examination in February 2020. The examiner conducted an in-person examination and reviewed the claims file. Statements of the Veteran were considered, including the fact that he had “complete” erectile dysfunction and did not see improvement with “many attempts” at medication. The Veteran reported trouble achieving and maintaining an erection. See February 2020 VA Male Reproductive System Conditions examination report. At the February 2020 VA examination, the Veteran was diagnosed with erectile dysfunction due to prostate cancer with a resulting prostatectomy. No retrograde ejaculation was present. The Veteran did not have a history of chronic epididymitis, epididymo-orchitis or prostatitis. No penis, testicular, or epididymis deformities or abnormalities were reported by the Veteran. No benign or malignant neoplasm or metastases were detected. No other pertinent physical findings or complications were observed or reported. The Veteran reported functional impact on his ability to work due to incontinence and low energy. See February 2020 VA Male Reproductive Systems Conditions examination report. Pursuant to the November 2020 Board remand, the Veteran took part in an additional VA Male Reproductive Organ examination in January 2021. See November 2020 Board Decision. The examiner conducted an in-person examination and reviewed the claims file. Statements of the Veteran were considered, including the fact that he was diagnosed with erectile dysfunction in June 2012 and did not see improvement with medication. The Veteran reported trouble achieving and maintaining an erection. See January 2021 VA Male Reproductive System Conditions examination report. At the January 2021 examination, the Veteran did not have a history of chronic epididymitis, epididymo-orchitis or prostatitis. No penis, testicular, or epididymis deformity or abnormality was reported by the Veteran. No benign or malignant neoplasm or metastases were detected. No other pertinent physical findings or complications were observed or reported. The Veteran reported no functional impact on his ability to work from the erectile dysfunction condition or its symptoms. See January 2021 VA Male Reproductive System Conditions examination report. In a VA medical opinion offered January 2021, an examiner stated the following: “I have reviewed the conflicting medical evidence and am providing the following opinion: Veteran does not have renal dysfunction as GFR was above normal, at 97 on February 4, 2020. Veteran has full and complete erectile dysfunction. He has had a Prostatectomy, which is known to sever the nerve related to erections. Medications for erection do not work for him. Veteran has no pain on urination but goes often. He has to wear absorbent material for constant leakage. This has to be changed 3-4 times a day. Most men can survive after having their prostate gland removed surgically. The same applies to those who have had it partially removed as well. However, researchers at Johns Hopkins Medicine revealed that when some men have their prostate partially or completely removed, it can lead to a decrease in luteinizing hormones. If this happens, testosterone levels will likely decline as well, which can cause a wide range of sexual dysfunction symptoms, according to researchers. The male anatomy runs off of testosterone, and this affects drive for sex and just about all things he likes to do.” See January 2021 VA Medical Opinion Addendum. Following a careful review of the record, the Board finds that the Veteran’s erectile dysfunction more nearly approximates the criteria for an initial rating of 20 percent under Diagnostic Code 7522. Physical examination in January 2021 revealed normal epididymis and testicles, with no abnormalities. However, the January 2021 VA examiner stated that a prostatectomy “is known to sever the nerve related to erections,” and that “[m]edications for erection do not work for him”, which suggests that the Veteran may in fact have a severed nerve due to his prostatectomy. The Board notes that “deformity” under Diagnostic Code 7522 means a distortion of the penis, either internal or external. See Williams v. Wilkie, 30 Vet. App. 134, 138 (2018). Given the Veteran’s difficulty achieving and maintaining an erection even with medications and the examiner’s suggestion that the Veteran has a severed nerve, the Board concludes that Veteran has not only a loss of erectile power, but also penile deformity. The Board need not consider whether the Veteran is entitled to an extra-schedular rating under 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Veteran. App. 49 (1996). The Board notes that the rating criteria for a 20 percent rating adequately compensates the Veteran for the symptoms attributable to his service-connected erectile dysfunction, namely loss of erectile power and deformity. Entitlement to a referral for extra-schedular consideration is not reasonably raised from the evidence of record or from the Veteran. Thun v. Peake, 22 Veteran. App. 111 (2008). Further, the Board does not note the existence of any evidence that would warrant separate, staged rating periods based on differing levels of disability or symptomatology during the appeal period. The evidence of record in connection with this claim for increase supports the conclusion that the Veteran is not entitled to additional increased compensation during any time within the appeal period. In summary, a preponderance of the evidence of record indicates that the Veteran meets the relevant criteria for a rating of 20 percent, and no higher, for erectile dysfunction under Diagnostic Code 7522. 2. Entitlement to a rating in excess of 60 percent for prostate cancer The Veteran seeks a rating in excess of 60 percent for prostate cancer. He has asserted that the 60 percent rating does not adequately compensate him for the difficulties caused by the disability. In an April 2021 brief, his representative argues that an 80 percent rating is warranted based on lethargy, weakness, and low tolerance for exertion. The Veteran’s prostate cancer is rated under 38 C.F.R. § 4.115b, Diagnostic Code 7528, which pertains to malignant neoplasms of the genitourinary system. Under Diagnostic Code 7528, a 100 percent evaluation is the highest schedular rating allowed for a malignant neoplasm of the genitourinary system. The Note following the rating criteria states, “Following the cessation of surgical, X-ray, antineoplastic chemotherapy or other therapeutic procedure, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months”, then, “If there has been no local reoccurrence or metastasis, rate on residuals as voiding dysfunction or renal dysfunction, whichever is predominant.” See 38 C.F.R. § 4.115b, Diagnostic Code 7528 Note. In relevant part, under 38 C.F.R. § 4.115a, for “Renal dysfunction” a 60 percent rating is assigned for constant albuminuria with some edema; or, definite decrease in kidney function; or, hypertension at least 40 percent disabling under diagnostic code 7101. An 80 percent rating is assigned for persistent edema and albuminuria with BUN 40 to 80 mg%; or, creatinine 4 to 8 mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. Finally, a 100 percent rating is assigned when regular dialysis is required, or more than sedentary activity is precluded from one of the following: persistent edema and albuminuria; or, BUN more than 80 mg%; or, creatinine more than 8 mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. See 38 C.F.R. § 4.115a, Renal dysfunction. For “Voiding dysfunction” 38 C.F.R. § 4.115a instructs to “Rate particular condition as urine leakage, frequency, or obstructed voiding.” A 60 percent rating is the highest possible schedular evaluation based on urine leakage and is assigned where there is a required use of an appliance or wearing of absorbent materials which must be changed more than 4 times per day. See 38 C.F.R. § 4.115a, Voiding dysfunction: urine leakage. The criteria for ratings based on urinary frequency or obstructed voiding do not provide for ratings in excess of the Veteran’s currently assigned 60 percent rating. Therefore, the Board will not discuss those criteria further. Turning to the evidence of record, the Veteran was awarded a 100 percent evaluation for prostate cancer based on active malignancy in a May 2012 rating decision. See May 2012 VA Rating Decision Narrative. The Veteran attended a VA Prostate Cancer examination in January 2013. His claims file was reviewed. He was examined by telephone, and his statements were considered by the examiner, including the fact that he was in early remission, post March 2012 radical prostatectomy surgery. The examiner noted a voiding dysfunction, with absorbent material requiring a change 2 to 4 times per day. No voiding appliance was reported to be used by the Veteran. No increased urinary frequency or obstructed voiding was documented by the examiner. The Veteran did not have a history of urinary tract or kidney infections. See January 2013 VA Prostate Cancer examination report. At the January 2013 VA examination, the Veteran reported a PSA (Prostate-Specific Antigen) test produced a result of 0.1 ng/mL. The Veteran reported functional impact on his work as a carpenter due to urinary incontinence. The bending, lifting, and squatting required with normal work activity increased his urinary leakage. See January 2013 VA Prostate Cancer examination report. A November 2013 treatment appointment documented, “No dysuria, hematuria, frequency, nocturia; since prostate surgery, has been needing one-two pads a day.” See November 2013 VA Physician Note. In a November 2013 rating decision, the evaluation for prostate cancer was decreased to 60 percent disabling, based on the wearing of absorbent materials for the Veteran’s urine leakage. See November 2013 VA Rating Decision Narrative. The Veteran timely appealed the rating decision, but expressly noted that he was asking for a higher rating for the prostate cancer and that he did not disagree with the reduction from a 100 percent rating. See January 2014 VA Form 21-0958, Notice of Disagreement. During a February 2018 treatment appointment, the Veteran reported, “Since prostate surgery, has been using ‘2-3 pads (per day) average.’” See February 2018 VA Physician Note. The Veteran attended a VA prostate cancer examination in February 2020. The examiner reviewed the claims file, examined the Veteran, and considered his statements, including the fact that his treatment included a radical prostatectomy in March 2013. The Veteran reported urinary leakage which required 2 to 4 absorbent pad changes daily. According to the Veteran, no appliance was required for the urinary leakage, and urinary frequency was every 2 to 3 hours during the day. A good initial urine stream was noted but with a short duration. No recurrent symptomatic urinary tract or kidney infections were reported. The Veteran’s prostate cancer was noted to be in remission. See February 2020 VA Prostate Cancer examination report. At the February 2020 VA examination, no retrograde ejaculation was detected, and no renal dysfunction was documented. No additional pertinent physical findings or complications were observed or reported. The Veteran’s GFR (Glomerular Filtration Rate) test was 97. The Veteran reported that his prostate cancer residuals impacted his ability to work due to urinary frequency, incontinence, and the need to sit when urinating. The Veteran also reported low energy and depression. See February 2020 VA Prostate Cancer examination report. A February 2020 VA medical opinion recorded the following: “I have reviewed the conflicting medical evidence and am providing the following opinion: Veteran has incontinence and has to wear pads, working down, or under a floor increases pressure on the bladder, and increases urination, and incontinence. He has to be discrete at work site. He can not use a urinal, and sitting is better for control of urine. Veteran states he has a global energy loss of at least 30 to 40 percent. And is doing very little work at all now. Veteran states he has a loss of drive for the things he likes to do across the board. He states because of the loss of sexual drive too, this adds to a daily low level of depression. Veteran fights this daily. Veteran denies medication for incontinence. He denies kidney dysfunction or the need for dialysis.” See February 2020 VA Medical Opinion. The Veteran underwent another VA Prostate Cancer examination in January 2021. The examiner reviewed the claims file, examined the Veteran, and considered his statements, including the fact that his residuals, namely urinary leakage, required 4 or more absorbent pad changes daily. According to the Veteran, no appliance was required for the urinary leakage, and urinary frequency was every 1 to 2 hours during the day and 3 to 4 times during the night. No recurrent symptomatic urinary tract or kidney infections were reported. The Veteran also reported a slow urine stream. See January 2021 VA Prostate Cancer examination report. The January 2021 VA examiner noted that the Veteran was diagnosed with prostate cancer in January 2012 and had a radical prostatectomy performed in March 2012. The cancer was considered to be in remission in January 2021. No additional pertinent physical findings or complications were observed or reported. The Veteran’s PSA (Prostate-Specific Antigen) Test produced a result of < 0.1 ng / mL of blood. The Veteran reported that his prostate cancer residuals did not impact his ability to work. See January 2021 VA Prostate Cancer examination report. The Note under Diagnostic Code 7528 provides for the ability to rate residuals of malignant neoplasms according to the “predominant” symptom(s). See 38 C.F.R. § 4.115b, Diagnostic Code 7528 Note. The record does not show that the Veteran has renal dysfunction as a result of his service-connected prostate cancer. No history of urinary tract or kidney infections was noted at his January 2013 VA Prostate Cancer examination, and his PSA test results were normal. See January 2013 VA Prostate Cancer examination report. At his February 2020 VA Prostate Cancer examination, no history of urinary tract or kidney infections was noted, his GFR test results were normal, and the Veteran denied kidney dysfunction or the need for dialysis. See February 2020 VA Prostate Cancer examination report and VA Medical Opinion. No recurrent symptomatic urinary or kidney infections were documented at his January 2021 VA Prostate Cancer examination, and his PSA test results were normal. See January 2021 VA Prostate Cancer examination report. The Board acknowledges the Veteran’s representative’s argument in the April 2021 that the Veteran has lethargy, weakness, and low tolerance for exertion such that an 80 percent rating is warranted. However, as the record does not show that he has renal dysfunction as a residual of his prostate cancer, which is a threshold requirement for assigning an 80 percent rating under the criteria referenced by the representative, an 80 percent rating is not warranted in this case. Regarding urinary leakage, at both his January 2013 and February 2020 VA Prostate Cancer examinations, the Veteran reported that his absorbent material “must be changed 2 to 4 times per day.” See January 2013 and February 2020 VA Prostate Cancer examination reports. At the November 2013 VA treatment visit, the Veteran reported “needing one-two pads a day.” See November 2013 VA Physician Note. The number of absorbent material changes was “2-3 pads average” in February 2018. See February 2018 VA Physician Note. The Veteran reported “more than 4 times per day” of absorbent material changes at the January 2021 VA examination. See January 2021 VA Prostate Cancer examination report. The Veteran has not required the use of an appliance for his urinary leakage. See January 2013, February 2020, and January 2021 VA Prostate Cancer examination reports. Based on the Veteran’s reported history of absorbent material changes, the rating criteria evaluates the “wearing of absorbent materials which must be changed more than 4 times per day” as 60 percent disabling. See 38 C.F.R. § 4.115b, Diagnostic Code 7528, urine leakage. The Veteran’s representative contended in an October 2018 brief that an extraschedular rating is warranted for the Veteran’s prostate cancer. The representative suggested that a rating should be assigned based on psychiatric manifestations related to his urinary leakage, “most likely depression.” Consideration of an extraschedular rating requires a three-step inquiry. The first question is whether the schedular rating criteria adequately contemplate the veteran’s disability picture. If the schedular evaluation does not contemplate the level of disability and symptomatology shown and is found inadequate, then the second inquiry is whether the exceptional disability picture exhibits other related factors, such as marked interference with employment or frequent periods of hospitalization. See Thun v. Peake, 22 Vet. App. 111 (2008). The first Thun element compares a claimant’s symptoms to the rating criteria, while the second addresses the resulting effects of those symptoms. Thus, the first and second Thun elements, although interrelated, involve separate and distinct analyses. Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). If the veteran’s disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Services to determine whether an extraschedular rating is warranted. See Thun, 22 Vet. App. 111. In regard to the first element, comparison of the Veteran’s symptoms and associated functional impairment does not show that the rating criteria are inadequate to describe his disability picture. The Veteran’s prostate cancer has been in remission throughout the relevant period and is manifested predominantly in urinary leakage. His current 60 percent rating considers his urinary leakage. The Veteran’s symptoms are therefore reasonably contemplated his rating under Diagnostic Code 7528. The threshold issue under Thun is thus not met, and further consideration of an extraschedular rating is not warranted. Regarding the contention that the Veteran has psychiatric symptoms due to his urinary leakage, there is no indication in the record that the Veteran has been diagnosed with a psychiatric disorder recognized by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Where a symptom or impairment is not compensable under the rating schedule, as is the case for psychiatric conditions without a valid DSM-5 diagnosis, see Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 404 (2020), it also does not warrant extraschedular consideration as this would amount to a backdoor means to obtaining compensation for a condition the rating schedule intends to exclude. See Long v. Wilkie, 33 Vet. App. 167 (2020). As there is no psychiatric condition validly diagnosed under the DSM-5, the Veteran may not be rated based on his reported psychiatric symptoms on a schedular or extraschedular basis as part of his appeal for a higher rating for prostate cancer. In summary, the record does not show that the Veteran has renal dysfunction as a result of his prostate cancer. Therefore a higher rating may not be assigned on that basis. The Veteran is already in receipt of the highest rating available based on voiding dysfunction. The current evaluation of 60 percent for urine leakage, requiring the wearing of absorbent materials which must be changed more than 4 times per day, more nearly approximates the Veteran’s current predominant symptoms. Further, the prohibition against the pyramiding of claims would prevent a combination of ratings for the same manifestation of symptoms under multiple diagnostic codes. The Board has carefully reviewed and considered the Veteran’s statements regarding the severity of his residuals of his prostate cancer disability. To that end, the Board acknowledges that the Veteran, in advancing this appeal, believes that the residuals are more severe than is reflected in the assigned evaluation rating. The Board is likewise aware of the Veteran’s contentions that the residuals of the prostate cancer disability impacts his daily activities. Moreover, the Board notes that the Veteran is competent to report observable symptoms such as voiding dysfunctions. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In this case, however, the competent medical evidence offering detailed, specific, and specialized determinations pertinent to the rating criteria, especially the determination regarding renal dysfunction, as determined by diagnosis, through laboratory and diagnostic testing and imaging, is the most probative evidence with regard to evaluating the pertinent symptoms for the disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The evidence also contemplates the Veteran’s descriptions of his symptoms both at his VA examinations and in treatment, including his reports of impairment with respect to limits on daily activities. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The January 2013, February 2020, and January 2021 VA examination reports are the most probative evidence of record on the question of entitlement to an increased rating. The reports are based on an extensive review of all of the evidence, including lay statements from the Veteran, were supported by a detailed rationale, provided data to support any conclusions, and provided a clear and reasoned analysis, the source of the most probative value in a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The VA examination reports provide compelling evidence against the Veteran’s claim for increase of his current 60 percent rating. There is no competent, credible evidence to refute the medical evidence of record. The weight of the probative evidence of record is against a finding that the Veteran is entitled to an increased disability rating of his prostate cancer residuals in excess of 60 percent. Therefore, his claim for increase must be denied, and his current rating of 60 percent is continued. In reaching the conclusions stated above, the Board has considered the applicability of the benefit of the doubt doctrine. The rule does not apply when the Board finds that a preponderance of the evidence is against the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). 3. Entitlement to a TDIU The Veteran contends that he “Can’t hear” and states, “My hearing is terrible.” See April 2019 VA Forms 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability and 21-4138, Statement in Support of Claim. As a result, the Veteran asserts, “[M]aintaining gainful employment within the meaning of the law is not feasible.” See April 2021 American Legion Appellate Brief. He has also stated that his service-connected prostate cancer residuals have made it difficult to stand and perform his work as a carpenter. VA will grant a TDIU when the evidence shows that a veteran is precluded, by reason of his service-connected disabilities, from securing or following “substantially gainful employment” consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. The central inquiry is “whether the Veteran’s service-connected disabilities alone are of sufficient severity to produce unemployability.” Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In determining unemployability for VA purposes, consideration may be given to a veteran’s level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). The sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough, as a high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (citing 38 C.F.R. §§ 4.1, 4.15, 4.16(a)). Medical evaluations are probative to understanding the level of functional impairment; however, the ultimate determination of unemployability is a legal question, not a medical one. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Recently, in Ray v. Wilkie, 31 Vet. App. 58 (2019), the Court defined the term “unable to secure and follow a substantially gainful occupation” in 38 C.F.R. § 4.16 to include two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the United States Department of Commerce as the poverty threshold for one person. The non-economic component includes consideration of: the veteran’s history, education, skill, and training; whether the veteran has the physical ability to perform the type of activities required by the occupation at issue; and whether the veteran has the mental ability to perform the activities required by the occupation at issue. TDIU may be assigned where the schedular rating is less than total and it is found that the Veteran is unable to secure or follow a substantially gainful occupation as a result of either (1) a single service-connected disability ratable at 60 percent or more, or (2) two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Service-connected conditions for the Veteran include: 1) prostate cancer, rated as 100 percent disabling from March 1, 2012, and 60 percent from February 1, 2014; 2) tinnitus, rated as 10 percent disabling from October 31, 2006; and 3) erectile dysfunction, associated with Prostate Cancer, rated as 20 percent disabling from March 7, 2012. The schedular percentage requirements for a TDIU are met because the Veteran’s prostate cancer was rated at least 60 percent disabling throughout the relevant period. The Veteran graduated from high school but does not have any post-secondary education or training. During his active service, the Veteran’s occupational specialty was armor reconnaissance specialist. See April 2019 VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. The Veteran described his duties in the Army as the driver of an “ACAV (Armored Combat Attack Vehicle).” See April 2014 VA Form 21-4138, Statement in Support of Claim. On his VA Form 21-8940, the Veteran indicated that his disabilities affected full-time employment in the year 2018. However, he did not report that he left his employment due to a service-connected disability. Rather, he indicated only that he was prevented from securing or following any substantially gainful occupation because he “Can’t hear.” He reported 32 years of self-employment as a carpenter. In response to “Time Lost From Illness,” the Veteran indicated “Not Much.” See April 2019 VA Form 21-8940, Veteran’s Application for Increased Compensation Based on Unemployability. The Veteran stated that he stopped working in March 2018. However, the February 2020 VA examiner reported from the Veteran “is doing very little work at all now.” See February 2020 VA Medical Opinion. Information regarding previous income levels is limited to the data the Veteran provided on the April 2019 VA Form 21-8940. On that Form, he reported that he earned $45,000 in the year 2015. An April 2019 VA request of the Veteran to complete VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, was not fulfilled. See April 2019 Correspondence. At his January 2013 and February 2020 VA examinations, the Veteran reported a functional impact on his ability to work due to urine leakage from bending, lifting, and squatting in construction work. See January 2013 VA Prostate Cancer and February 2020 VA Medical Opinion, Prostate Cancer, and Male Reproductive System Conditions examination reports. The Veteran did not report a functional impact on his ability to work in either of his January 2021 VA examinations. See January 2021 VA Medical Opinion, Prostate Cancer, and Male Reproductive System Conditions examination reports. Further, January 2021 VA Individual Unemployability Statements for prostate cancer and male reproductive system conditions noted ““No restrictions for job activities required.” See January 2021 Individual Unemployability Statement (Prostate Cancer) and (Male Reproductive System Conditions). Regarding the Veteran’s service-connected tinnitus, the examiner stated, “With proper hearing and / or adaptive devices, the Veteran has no work restrictions for hearing loss or tinnitus.” See January 2021 Individual Unemployability Statement (Hearing Loss and Tinnitus). Although the Veteran meets the rating requirements for consideration of a schedular TDIU from February 1, 2014, there the evidence does not show that he is unemployable due to a service-connected disability. While the Veteran argues that his service-connected disabilities preclude him from obtaining and maintaining substantially gainful employment (See October 2018 and April 2021 American Legion Appellate Briefs), the Veteran was self-employed as a carpenter from 1986 to 2018. The Veteran indicated that he earned $45,000 in the year 2015. See April 2019 VA Form 21-8940. As such, the Board finds that the Veteran’s employment cannot be considered marginal, as his income exceeds the poverty level for 2 people. See U.S. Department of Health and Human Services Federal Poverty Guidelines. Based upon the foregoing evidence, the Board concludes that the Veteran’s service-connected conditions do not prevent him from securing or following a substantially gainful occupation, consistent with his work history, education, skill, and training. While the Veteran’s service-connected conditions have the potential to functionally impact his employment, as indicated in the January 2013, February 2020, and January 2021 VA examinations, the standard under 38 C.F.R. § 4.16(a) is whether the disabled person is unable to secure or follow a substantially gainful occupation. For at least 32 years, which includes more than 5 years of employment in construction post prostate cancer diagnosis, the Veteran has done so. According to the Veteran, hearing loss, a condition for which he is not service connected, prevents him from securing or following any substantially gainful occupation. The evidence does not show that the Veteran’s service-connected conditions limited his work to the degree required for a TDIU. There is no probative evidence showing that the Veteran’s erectile dysfunction affects the Veteran’s ability to secure or follow a substantially gainful occupation. The evidence shows that he would have not limitations due to his tinnitus as long as he uses proper hearing and/or adaptive devices. Bending, lifting, and squatting would exacerbate his urinary dysfunction due to prostate cancer. He would also need ready access to a bathroom due to his urinary dysfunction. However, he would be able to perform any number of sedentary jobs, such as sorting work, inspection work, and assembly work, which do not involve exertional activities or postural activities beyond his residual functional capacity in view of his service-connected disabilities. In that regard, the Board notes that the term “sedentary” is defined for purposes of this decision as work that requires no more than 2 hours of standing and/or walking in an 8-hour workday and involves light lifting of no more than 10 pounds. In determining whether the Veteran is entitled to a TDIU, the Board has also considered the Veteran’s level of education and previous work experience. See 38 C.F.R. §§ 4.16. The Veteran has indicated that he has a high school education. The Board finds that the Veteran’s education level is not inconsistent with an ability to perform work of an unskilled or semi-skilled nature, such as sorting, inspection, or assembly work. The Veteran has past work experience as a carpenter. The Board finds that although the Veteran may no longer be able to perform his past work, his work history would not prevent him from transitioning to an unskilled or semi-skilled sedentary occupation, or from securing or following an unskilled or semi-skilled sedentary occupation, which do not require special training and can be learned on the job site. The Board does not doubt that the Veteran’s service-connected disabilities limit his occupational functioning. However, as discussed above, the Veteran has retained the functional capacity to perform the duties required of any number of sedentary jobs that do not involve bending, squatting, or heavy lifting and would allow for ready access to a bathroom, such as sorting work, inspection work, and assembly work. Accordingly, the Veteran’s claim for a TDIU is denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. T. J. ANTHONY Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Small, Attorney Advisor 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.