Citation Nr: 21026881 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 15-04 670 DATE: May 4, 2021 ORDER Entitlement to service connection for erectile dysfunction is granted. FINDING OF FACT Resolving the benefit of the doubt in favor of the Veteran, his erectile dysfunction is secondary to service-connected acquired psychiatric disabilities. CONCLUSION OF LAW The criteria for service connection for erectile dysfunction due to service or service-connected acquired psychiatric disorder disabilities are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1967 to October 1969. He has confirmed service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In August 2018 and November 2020, the Board remanded the claim for additional development. The Board also remanded the matter of entitlement to an effective date earlier than December 31, 2014, for the grant of service connection for prostate cancer for a statement of the case (SOC). The RO issued a SOC in January 2021; the Veteran did not perfect an appeal. As such, that issue is not before the Board. 1. Entitlement to service connection for erectile dysfunction The Veteran seeks service connection for erectile dysfunction. He contends that his erectile dysfunction is secondary to his service-connected prostate cancer, service-connected chronic lumbar strain, or service-connected adjustment disorder. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current erectile dysfunction disability that is proximately due to or the result of, or is aggravated by his service-connected prostate cancer, chronic lumbar strain, or adjustment disorder. VA treatment records reflect a history of erectile dysfunction. In September 2004, the Veteran reported sexual dysfunction. He reported that he wanted to try Viagra. Treatment providers assessed psychosexual dysfunction with inhibited sexual excitement. Later treatment records list erectile dysfunction as a medical problem. The Veteran was afforded a VA examination in March 2014. The Veteran asserted that his erectile dysfunction was related to his back as well as his prostate cancer. The examiner opined the Veteran's erectile dysfunction is unrelated to the Veteran's back disability. She explained that review of the claims file showed that he was diagnosed with psychosexual dysfunction with inhibited sexual excitement in 2004. The Veteran was afforded a VA examination in February 2016. The examiner opined the claimed condition is less likely proximately due to the Veteran's low back disability. The examiner explained that the Veteran was diagnosed with erectile dysfunction in 2004, at the age of 56. He explained that there was no available medical documentation providing evidence that the Veteran's erectile dysfunction is associated with his low back disability. He attributed the onset of the Veteran's erectile dysfunction to advancing age. The examiner further opined the Veteran's erectile dysfunction is less likely as not aggravated beyond its natural progression by the lumbar spine condition. He explained there was no evidence of baseline or deviation from a baseline to document aggravation of erectile dysfunction. The Veteran was afforded a VA examination in February 2018. The examiner opined the Veteran's erectile dysfunction is not as likely as not attributable to his service-connected prostate cancer. She explained that erectile dysfunction was first documented in 2004, which also indicated the etiology of the Veteran's erectile dysfunction as psychosexual dysfunction. The Veteran was afforded a VA examination in November 2018. The examiner opined that the Veteran's erectile dysfunction is not as likely as not attributable to his prostate cancer. He explained that the Veteran has erectile dysfunction, with the etiology in treatment records of psychosexual dysfunction with inhibited sexual excitement. Thus, he concluded erectile dysfunction is less likely than not attributable to prostate cancer. The Veteran was afforded a VA examination in October 2019. The Veteran reported that he began experiencing erectile dysfunction in 2014. The examiner opined that the Veteran's erectile dysfunction was less likely than not incurred in or caused by the service-connected prostate cancer disability. She explained that the Veteran was diagnosed with erectile dysfunction in 2004. However, the Veteran's prostate cancer was first diagnosed in 2014. Thus, she concluded it is less likely than not the Veteran's erectile dysfunction, which occurred 10 years prior to the prostate cancer, is proximately due to his prostate cancer. In an October 2019 addendum opinion, she clarified that there the Veteran's prostate cancer also did not aggravate his erectile dysfunction. In November 2020, the Board remanded the claim to obtain a secondary service connection opinion to address causation or aggravation by the Veteran's service-connected psychiatric disorder. If necessary, the RO was directed to refer the case to a psychiatrist or psychologist to consider the impact of the Veteran's service-connected psychiatric disorder on his sexual functioning. In December 2020, a VA examiner reviewed the claims file. She opined that available documented in September 2004 noted the screen for PTSD was positive, and that the Veteran was diagnosed with erectile dysfunction in 2004. However, she explained that the available medical records did not note any medical evaluations for erectile dysfunction due to or related to an acquired psychiatric disorder. She determined there was a lack of sufficient objective medical evidence in the medical records to confirm that the Veteran's erectile dysfunction has been caused or aggravated by his service-connected psychiatric disorder. Thus, she concluded a nexus had not been established. In January 2021, she offered an addendum opinion. She clarified that erectile dysfunction has many different causative factors, and is not strictly due to psychological factors. These factors can include heart disease, high blood pressure, obesity, certain prescription medications, tobacco and alcohol use, stress, depression, or relationship problems. She concluded that the etiology and underlying causes of psychosexual dysfunction with inhibited sexual excitement would be best addressed by a psychologist or mental health provider, since making a determination regarding the Veteran's psychosexual dysfunction and erectile dysfunction was outside her scope of practice. In February 2021, a VA psychologist reviewed the claims file. She opined that there is not sufficient evidence to confirm the Veteran's erectile dysfunction hs been caused or aggravated by his service-connected adjustment disorder. She concurred with the January 2021 opinion that erectile dysfunction can be caused by multiple stressors including heart disease, high blood pressure, obesity, certain prescription medications, tobacco and alcohol use, stress, depression, relationship problems, and age. She noted the Veteran had a history of prostate cancer. To the extent the opinion suggests a relationship between prostate cancer and erectile dysfunction, the Board gives greater weight to the October 2019 VA opinion which more specifically considered the possible relationship between the Veteran's erectile dysfunction and prostate cancer. She further explained that an October 2019 mental health report indicated mild mental health symptoms, which would not suggest psychological factors were a main driver in the Veteran's erectile dysfunction. The Board concludes that, when resolving the benefit of the doubt in favor of the Veteran, service connection for erectile dysfunction is warranted. The January 2020 VA examiner concludes that the Veteran's erectile dysfunction was likely due to psychosexual dysfunction. In February 2021, the VA examiner acknowledged that the cause of erectile dysfunction was multifaceted, and that stress and depression could both be causative factors. These factors were not ruled out by the examiner. Given these two VA examinations, without evidence to refute the opinions reached, the Board finds that it is at least as likely as not that the Veteran's erectile dysfunction was caused or aggravated, by any degree, by his service-connected psychiatric disorder. R. Erdheim Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Lauritzen, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.