Citation Nr: 21025677 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 17-57 886 DATE: April 28, 2021 ORDER Entitlement to service connection for urethral stricture is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran’s current urethral stricture began during active service, or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for urethral stricture have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1964 to June 1967. His military awards and decorations include the Purple Heart with one star. In May 2019, the Board remanded this matter for further evidentiary development. Entitlement to service connection for urethral stricture. The Veteran seeks service connection for urethral stricture because he believes his current urethral stricture is related to scarring from a hematuria in service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. After reviewing the record, the Board concludes that, while the Veteran has a current disability of urethral stricture, as shown on prior VA examinations and in VA treatment records, the preponderance of the evidence of record is against a finding that that the Veteran’s current urethral stricture began during service, is otherwise related to an in-service injury, event, or disease. Service treatment records (STRs) show that in May 1966, the Veteran noted the onset of dark brownish urine, and urinalysis revealed hematuria. It was felt that this was possibly due to trauma secondary to carrying a heavy pack on his back. The Veteran denied any associated urinary tract symptoms. A May 1966 cystoscopy was within normal limits. Thereafter, a February 1967 cystoscopy and pyelogram were performed and were within normal limits. It was noted that urine from the left kidney showed microhematuria, which was felt to most likely result from a small renal lesion precipitated by carrying a heavy pack in service. In March 1967, a report of Physical Evaluation Board (PEB) proceedings recommended the Veteran be found unfit to perform the duties of his rank, in part, due to left renal hematuria, etiology undetermined. VA records show that the Veteran was hospitalized from April – May 1967 and again in November 1967, for further evaluation of hematuria that was noted in 1966 during service, with no associated urinary tract symptoms or history of trauma. During these hospitalizations, it was noted that a cystoscopy was within normal limits, and a panendoscopy showed erythema of the membranous urethra and marked urethritis. In November 1967, the Veteran was discharged with a diagnosis of benign essential hematuria, and without any restrictions. Post-service treatment records from a private urologist, Dr. P., show the Veteran was not diagnosed with urethral stricture until January 2000, approximately 29 years after his separation from service, and that at the time of that diagnosis, he denied any history of urethral stricture. Dr. P. also noted in a May 2015 Urinary Tract Conditions Disability Benefits Questionnaire (DBQ), that the urethral stricture was first diagnosed in 2000. Additionally, January 2000 treatment records from Dr. P. show that the Veteran reported he had been under the care of a urologist for 2 years for “BPH” and “PSA,” and had a history of hematuria since service, and started to have dysuria and urinary frequency in December 1999. Later in January 2000, he underwent a flexible cystoscopy, which revealed a severe pinpoint urethral stricture at the bulbous area. Thereafter, in February 2000, a repeat flexible cystoscopy was done, which revealed a bulbous urethral stricture had recurred. The impressions included bladder outlet obstruction secondary to urethral stricture, bladder diverticulum, and hematuria due to urethral stricture. In March 2000, the doctor advised they were dealing with a very tight scar and that the scar would always come back even though it was dilated. The Veteran reported he had a history of three cystoscopies while in service, and the doctor indicated this “tells me he was having urethral problems at that time”, but the Veteran “claims he was never informed of any problem”. Thereafter, treatment records show that every three months through July 2015, the Veteran underwent repeat cystoscopy dilatation for urethral stricture. In a May 2015 statement, the Veteran reported he had to go to the emergency room because his urethra was completely blocked from scarring and he could not pass urine. He reported he had been seen regularly by a urologist since the 1980s, and that “as far as cause undetermined, it could have been when [they] were overrun by Vietcong and percussion grenades were thrown in [their] trenches” for which a Purple Heart was awarded. In the May 2015 Urinary Tract Conditions DBQ, completed by Dr. P., it was noted that urethral stricture was diagnosed in January 2000, that the Veteran was seen first in January 2000 with urinary retention and pyuria, at which time a cystoscopy showed a pinpoint stricture at the bulbous urethra was dilated. It was also noted that the Veteran had been seen regularly since 2000 for cystoscopy with dilatation of urethral stricture, and had scars related to urethral stricture. Dr. P. did not offer an opinion as to the etiology of the urethral stricture. On an October 2016 VA DBQ examination, it was noted that the Veteran’s urethral stricture was diagnosed in 2000. The Veteran reported recurrent urethral strictures for the past 15-20 years, and indicated he had been seeing a urologist for dilatation every 3 months, which recently changed to every 6 months. The examiner opined that the Veteran’s urethral stricture was less likely than not due to the service-connected hematuria, as hematuria was not an etiology for the development of urinary strictures. In a statement accompanying his October 2017 VA Form 9, substantive appeal, the Veteran indicated he was seeking service connection for urethral stricture caused by scarring. He reported that even though he did not have treatment during service for this complaint, it did not mean it was not caused by service, especially when percussion grenades were thrown in their trenches, and that it took years for the scarring to form and restrict the flow. The Veteran also reported that he had been seeing a urologist since the early 1980s, and at his most recent visit last month, Dr. P. instructed he increase use of self-dilatation with urinary catheter from once a week to twice a week. On a VA DBQ examination report in November 2019, it was noted that the Veteran’s urethral stricture had an onset in December 1999, at which time he began to experience urinary retention and dysuria. The examiner opined that the Veteran’s urethral stricture was not incurred in or caused by an injury or disease in service. For rationale, the examiner noted that the 1964 enlistment physical was silent for urinary symptoms, and that in 1966 he began to experience hematuria, and underwent two cystoscopies for evaluation of hematuria – the first of which was normal and the second showed erythema of the membranous urethra and marked urethritis, but urethral stricture was not seen on either. The examiner noted that service records did not show the onset of urethral stricture during service. The examiner also opined that the Veteran’s urethral stricture was not proximately due to or the result of either erythema of the membranous urethra or urethritis, both of which were noted in service. The examiner noted post-service treatment records were silent for urinary symptoms until December 1999, when the Veteran was diagnosed with urethral stricture, and that after being seen by urology in January 2000, he underwent multiple cystoscopies every 3-6 months, but none showed chronic urethritis. The examiner noted that although infectious urethritis (mostly caused by gonorrhea urethritis) can cause scarring and stricture of the urethra, gonorrhea urethritis was not noted in his records, and that the urethritis that occurred in 1967 appeared to be acute and self-limiting since there was no records of documented symptoms/treatments for chronic urethritis for over 30 years, and no findings of chronic urethritis during cystoscopy procedures since 2000. In an August 2020 statement, the Veteran contended the 2019 VA examiner failed to note he had been treated for urethral stricture for years before 1999, and that he "thought she wrote down all the things I told her". He reported that after 1970 he saw a urologist who found a pea-sized lump in his scrotum, and that he still had blood in his urine and frequency of urination, and made yearly visits to the urologist after that. He reported that in 1985 he had to go to the urologist for painful urination, in 1993 got another urologist that he saw every 6 months for urethral stricture and trace blood in urine, and in 1999 he started seeing Dr. P. for urethral stricture. The Veteran indicated Dr. P. asked if he ever had a blow in the genital area because of his internal scarring in the urethra, and that he told Dr. P. this only happened in service in Vietnam when grenades were thrown in his trench. In considering the claim for service connection, the Board finds the 2016 and 2019 VA examiner's opinions to be probative and persuasive, because they are based on an accurate medical history, including consideration of treatment for urethritis and hematuria in service and post-service treatment records, and provide an explanation and rationale that contains clear conclusions and supporting data. Additionally, the examiners addressed all theories of entitlement, including the Veteran’s contention that his urethral stricture was related to scarring from urethritis. The Board also notes that the Veteran has not submitted competent medical evidence to the contrary. While the Veteran is competent to report any symptoms he experienced, including urinary symptoms, he is not competent to provide a diagnosis or to opine that any current urethral stricture is related to service. The issue of nexus is medically complex and outside the competence of the Veteran because the record does not show he has the skills or medical training to make such a determination. Kahana v. Shinseki, 24. Vet. App. 428 (2011). Additionally, while the Veteran contends he was treated for urethral stricture prior to 1999/2000, post-service treatment records show otherwise, and also show that in January 2000, he denied a history of urethral stricture. Consequently, the Board gives more probative weight to the 2016 and 2019 VA examiner's opinions. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Casula 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.