Citation Nr: 21028505 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 15-07 593 DATE: May 11, 2021 ORDER Service connection for kidney stones is denied. Service connection for enlarged prostate is denied. REMANDED Service connection for hypertension is remanded. Service connection for erectile dysfunction is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that a recurrent kidney stone condition began during active service or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that an enlarged prostate began during active service or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for kidney stones are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for enlarged prostate are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1968 to April 1969, including service in the Republic of Vietnam from September 1968 to April 1969, with additional service in the Navy Reserve from November 1967 to January 1994, with various periods of active duty for training (ACDUTRA). This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for recurrent nephrolithiasis (kidney stones), benign prostate hypertrophy (BPH), hypertension, hyperlipidemia, and erectile dysfunction and denied special monthly compensation for loss of use of a creative organ. In a July 2013 notice of disagreement, the Veteran initiated an appeal of the denials of service connection for recurrent nephrolithiasis (kidney stones), benign prostate hypertrophy (BPH), hypertension, and erectile dysfunction. The RO issued a statement of the case in January 2015 and the Veteran perfected his appeal with a VA Form 9 later that month. In November 2018, the Board remanded this case for further development. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Active service includes active duty; any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty for training (IDT) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty; or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident occurring during such training. 38 U.S.C. § 101 (24); 38 C.F.R. § 3.6. 1. Service connection for kidney stones The Veteran contends that he has recurrent kidney stones that began during service. 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. The Board concludes that, while the Veteran has a diagnosis of nephrolithiasis (kidney stones), the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. VA did not obtain a medical nexus opinion on this issue. VA must provide a medical examination and medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). Here, the evidence does not show a relevant in-service disease or injury. His service treatment records do not show complaints of or treatment for kidney stones during the Veteran's active duty military service from May 1968 to April 1969. Furthermore, the Veteran repeatedly denied a history of or current kidney stones in his reports of medical history during his Navy Reserve service through July 1986. The first mention of kidney stones in the record was a June 1987 report of medical history, nearly two decades after the Veteran's separation from active duty service, which notes treatment for kidney stones approximately three months prior. The June 1992 exam notes asymptomatic renal calculi (kidney stones). While this coincides generally with his more than two decades of service in the Navy Reserves, the record does not suggest and the Veteran has not identified any injury during a period of ACDUTRA or IDT to which this disability can be linked and the reference to the initial diagnosis in approximately March 1987 does not suggest that the Veteran was serving a period of ACDUTRA at that time. Instead, this condition seems to have been first diagnosed in his civilian life outside of his Reserve service. As such, there is no in-service injury or disease to which this condition can be causally linked. As such, an opinion is not necessary. The April 2012 private opinion found that the Veteran's nephrolithiasis (kidney stone) condition was more likely than not a continuance or, related to, or aggravated by his military service, in-service injuries and/or treatment. The rationale was that the Veteran had recurrences of kidney stones three times during service and his post-service private treatment records show a continuation of this condition. The medical literature state that patients with initial kidney stones have a high prevalence of reoccurrence. Thus, this was a chronically recurrent condition with recurrence intervals varying based on the patient's adoption of modifiable factors in his or her lifestyle. Per the Veteran's reported history, he had tried to prevent recurrence by making dietary changes. Here, the Veteran's kidney stones have not been linked to a specific period of ACDUTRA or IDT during his time as a Navy Reservist and so no in-service occurrence has been established. As this opinion is erroneously based on the assertion that the Veteran's kidney stones first manifested during service, it is not probative. While the Veteran believes his kidney stones are related to his military service, the Board reiterates that the preponderance of the evidence weighs against findings that an associated in-service injury, event, or disease occurred given that the record suggests an onset of symptoms during his civilian life. For the reasons stated above, the Board finds that the preponderance of evidence is against the Veteran's claim of entitlement to service connection for kidney stones and his appeal must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Service connection for enlarged prostate The Veteran contends that his benign prostatic hyperplasia (BPH) is began in service or was causally linked to her service-connected diabetes mellitus. 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. The Board concludes that, while the Veteran has a diagnosis of BPH, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. VA did not obtain a medical nexus opinion on the question of direct service connection because the evidence does not show a relevant in-service disease or injury. His service treatment records do not show complaints of or treatment for any prostate condition during the Veteran's active duty military service from May 1968 to April 1969. The first mention of an enlarged prostate in the record was a July 1989 examination, two decades after the Veteran's separation from active duty service, which notes 1+ prostate enlargement. Again, while this coincides generally with his of service in the Navy Reserves, the record does not suggest and the Veteran has not identified any injury during a period of ACDUTRA or IDT or an onset of disease during a period of ACDUTRA to which this disability can be linked. Instead, the first reference to this is an annual exam during Reserve service. As such, there is no in-service injury or disease to which this condition can be causally linked. As such, an opinion is not necessary. The April 2012 private opinion found that the Veteran's prostate enlargement was more likely than not a continuance or, related to, or aggravated by his military service, in-service injuries and/or treatment. The rationale was that prostate enlargement was shown in the service treatment record (prostate size of 1+ on an annual exam) and his current condition is most probably a continuation of that enlargement. Here, the Veteran's BPH has not been linked to a specific period of ACDUTRA or IDT during his time as a Navy Reservist and so no in-service occurrence has been established. As this opinion is erroneously based on the assertion that the Veteran's enlarged prostate first manifested during service, it is not probative. While the Veteran believes his BPH is related to his military service, the Board reiterates that the preponderance of the evidence weighs against findings that an associated in-service injury, event, or disease occurred given that the record suggests an onset of symptoms during his civilian life. Alternately, 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 disability that is proximately due to or the result off or was aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran has a current disability BPH, the preponderance of the evidence is against finding that the Veteran's BPH is proximately due to or the result of or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The November 2012 VA male reproductive system conditions DBQ examiner opined that the Veteran's BPH was less likely than not proximately due to or the result of the Veteran's service-connected diabetes mellitus. The rationale was that his diagnosis of +1 BPH in 1989 was not uncommon for a 41-year-old. He was not diagnosed with hyperglycemia until 2008. There was no medical evidence to support an effect of diabetes on the prostate gland nor did the Veteran report any change of symptoms or exam findings. He discontinued his alpha-blockers without change of symptoms. The Veteran believes his BPH is proximately due to, the result of, or aggravated beyond its natural progression by a service-connected disability. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of interaction between multiple organ systems in the body and pathology. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the November 2012 opinion. For the reasons stated above, the Board finds that the preponderance of evidence is against the Veteran's claim of entitlement to service connection for enlarged prostate and his appeal must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. REASONS FOR REMAND 1. Service connection for hypertension is remanded. The November 2012 VA hypertension DBQ examiner's negative secondary aggravation opinion is based in part on a finding that there had been no change in antihypertensive treatment has been made since the initial hypertension diagnosis, which predated the diabetes diagnosis. The April 2020 VA treatment record shows that the Veteran's blood pressure is not at the target level. It is unclear if this reflects recent aggravation due to a service-connected disability. As such, an addendum opinion is necessary to address this and whether the Veteran's hypertension is proximately due to or aggravated beyond its natural progression by his service-connected coronary artery disease. 2. Service connection for erectile dysfunction The November 2012 VA male reproductive system conditions DBQ examiner's negative secondary service connection opinion is based in part on the order in which these disabilities were diagnosed, noting that the Veteran's diagnosis or erectile dysfunction preceded his diabetes mellitus diagnosis by two years. The Veteran's representative has argued that the Veteran was pre-diabetic at that time and the examiner did not adequately address whether his erectile dysfunction could be related to his pre-diabetes, which was eventually diagnosed as diabetes and service connected. As such, an addendum opinion is necessary to address this contention. The matters are REMANDED for the following action: 1. Obtain an additional opinion from an appropriate clinician regarding whether the Veteran's hypertension is at least as likely as not proximately due to or aggravated beyond its natural progression by service-connected disability, to include diabetes mellitus and coronary artery disease. 2. Obtain an additional opinion from an appropriate clinician regarding whether the Veteran's erectile dysfunction is at least as likely as not proximately due to or aggravated beyond its natural progression by his service-connected diabetes, to include a period of pre-diabetes prior to the official diagnosis of this disability. (Continued on the next page) 3. Finally, readjudicate the claim on appeal. If any benefit sought on appeal remains denied, then furnish the Veteran and his attorney with a supplemental statement of the case and allow them an opportunity to respond. ERIC MINE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Houbeck 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.