Citation Nr: 21030739 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 15-06 337A DATE: May 19, 2021 ORDER Entitlement to service connection for a chronic bladder disease (claimed as urinary incontinence) is denied. FINDING OF FACT The preponderance of the evidence of record is against finding that the Veteran has had a chronic bladder disease at any time during or approximate to the pendency of the claim. CONCLUSION OF LAW The criteria for service connection for a chronic bladder disease are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1984 to June 2006. This matter comes to the Board of Veterans' Appeals (Board) from a decision of the Agency of Original Jurisdiction (AOJ). In November 2013, the AOJ issued a rating decision that denied the Veteran's claims for service connection for a bladder disability. The Veteran timely disagreed in a December 2013 Notice of Disagreement (NOD) and perfected her appeal in a March 2015 VA Form 9. In July 2019, a Board hearing was conducted. The hearing transcript has been associated with the Veteran's file. Then in March 2020, the Board issued a remand for a Supplemental Statement of the Case (SSOC) that considered newly submitted evidence. This case was returned to the Board for appellate review in March 2021 after the AOJ substantially complied the Board's remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that the Veteran's representative has raised the issue of entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities; however, the Board is not taking jurisdiction over the issue of entitlement to a TDIU at this time. When evidence of unemployability is received during the course of an appeal of an assigned disability rating, a claim for a TDIU due to that disability will be considered to have been raised by the record as "part and parcel" of the underlying increased rating claim. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). While a January 2020 Statement of the Case (SOC) was issued that denied entitlement to a TDIU, the claim currently before the Board is a service connection claim, and no disability rating has yet to be assigned. The record does not show that the Veteran perfected an appeal of the TDIU issue following the January 2020 SOC. Thus, entitlement to a TDIU is not part of the appeal before the Board at this time. Entitlement to service connection for a chronic bladder disease (claimed as urinary incontinence) The Veteran contends she has a bladder disease that began during service. See Transcript dated July 2019 at 3. The question for the Board is whether the Veteran has had a bladder disease at any time during the appeal period. For the reasons discussed below, the Board concludes the evidence does not support finding that she has had a current disability or has had one at any time during the appeal period. Entitlement to service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (2007). Beginning with the Veteran's service, her entrance examination does not note symptoms associated with a chronic bladder disease. Part of that examination included a questionnaire that allowed the Veteran to report observations of any maladies. She did not report observations or complaints of a bladder disease. See April 23, 1984, Report of Medical Examination and Medical History. The Veteran's service treatment records (STRs) show she complained of difficulties controlling her urination after she entered service and throughout her military career. Her STRs indicate the first complaint of urinary incontinence was made in December 1987, several times between 1993 and 1994, and a few times between 2000 and 2002. In December 1987, during an emergency room visit for complaints of abdominal pain, she reported difficulty controlling urination. See December 8, 1987, STR. Similar reports accompanied complaints of abdominal pain in October 1993 as well as January and February 1994. See STRs dated October 12, 1993; January 12, 1994; February 7, 1994. Then in February 1994 she started to visit sick-call specifically for complaints of urinary incontinence. She did so again in March 1994, September 2000, and September 2002. See STRs dated February 9, 1994; March 11, 1994; September 21, 2000; September 12, 2002. Some of those visits led to the diagnosis of urinary tract infection. A diagnosis of a bladder disease was not found with those records. The Veteran underwent a separation examination in March 2006. She reported frequent or painful urination. See March 3, 2006, Report of Medical History at 1. The examiner who evaluated her report noted she has frequent urination. Id. at 3. The military doctor's clinical examination of the Veteran does note a bladder disease. See March 2006 Report of Medical Examination. The following year following, in March 2007, the Veteran underwent her first VA disability examination for a bladder disease. She reported she observed occasional urinary leakage and believed it to be related to a bladder condition. She has discovered that supportive underwear and control of fluid intake helped control her urinary leakage. She denied she had been treated for stress incontinence. See March 2007 Compensation and Pension (C&P) Examination at 5. The examiner noted the Veteran has not had surgery on her bladder. Also, she does not have renal disease and even though she had been treated for urinary tract infection over the past year, she does not have chronic urinary tract infections. Id. The examiner concluded the Veteran does not have a chronic bladder disease. He did not provide a rationale to support his conclusion. Id. In August 2012, the VA received a statement from the Veteran wherein she reported she has suffered from urinary incontinence since 1994. She reported she has observed urinary leakage when she coughed, sneezed, laughed, and strained. She tried to control it by limiting her intake of fluids. She indicated she cannot control it and wears pads every day to deal with urinary leakage. See August 2012 Statement. In November 2017, the Veteran underwent a VA disability examination for gynecological conditions. In addition to reports related to sexual desire and uterine fibroids, she reported problems with urinary leakage when she coughed or strained. See VA Disability Benefits Questionnaire (DBQ) at 6. The examiner noted the Veteran has stress incontinence/leakage without a known etiology. She also noted it was not due to a gynecologic condition. Id. at 6. The examiner did not find a rectovaginal fistula, which is an abnormal passage between the rectum and vagina. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (DORLANDS) 705 (33rd ed. 2020). Nor a urethrovaginal fistula, which is an abnormal passage between the urethra and vagina. Id. at 6. The examiner diagnosed uterine fibroids, menorrhagia, female sexual disorder (FSAD). Id. at 2. She also noted those diagnoses do not impact the Veteran's ability to work. Id. at 9. In October 2018, the Veteran underwent another VA disability examination for gynecologic conditions. In addition to reports related to sexual desire and uterine fibroids, she reported problems with occasional urinary leakage when she coughed or strained. She reported it began after childbirth. She added that even though she has not been treated by a doctor for urinary incontinence, she has found ways to limit urinary leakage to include wearing of supportive underwear and limited consumption of fluids. See VA DBQ at 2, 5, 8. On examination, the examiner noted the Veteran's urinary incontinence is not related to a gynecologic condition. Id. at 5. The examiner did not find a rectovaginal or urethrovaginal fistula. Id. The examiner noted the diagnoses of FSAD and uterine fibroids without other complications, conditions, or symptoms not noted in the examination. Id. at 2, 7. She also noted those diagnoses do not impact the Veteran's ability to work. Id. at 8. Then the examiner concluded that the Veteran cannot be diagnosed with stress incontinence at that time. Based on the examiner's notes, she explored other conditions that are relevant to diagnosing stress incontinence, to include renal disease and chronic urinary tract infections. In support of her conclusion, the examiner referred to prior examinations where a chronic disability and stress incontinence were not found. Id. at 8. In July 2019, a Board hearing was conducted for the Veteran's entitlement claim. The Veteran testified her bladder disease began during service. She reports she observed urinary leakage more than once a week during training and, at times, wet herself because she could not make it to the bathroom in time. She addressed her symptoms by wearing absorbent pads while in training. She added that she tried to complain to service medical providers but tended to miss her appointments at no fault of her own. She testified she tended to get reassigned to another duty station before her scheduled appointments. See Transcript at 3. She testified she observed urinary leakage following service as well. She has observed leakage that occurs when she physically exerts herself. Id. at 6. She saw medical professionals following service to evaluate her reports of urinary leakage and was informed it may be due to straining. She did not assert she was told of a specific medical diagnosis for her observed symptoms. Id.at 4. Turning to the Veteran's claim for disability compensation, the first issue is whether the Veteran has had a chronic bladder disease or disorder during the period on appeal. The November 2017 and October 2018 VA DBQs weigh strongly against finding the Veteran had a chronic bladder disease at any time across the appeal period. See November 2017 VA DBQ at 2, 6; October 2018 VA DBQ at 2, 8. The examiners considered the evidence of record, their personal examinations, and the Veteran's lay observations. So, the Board finds they were informed of the relevant details of the Veteran's past medical history when rendering their conclusions. Nievez-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2006). Although the examiners found the Veteran has urinary incontinence, they did not diagnose a bladder disease or associate it with any diagnosed gynecological disorder. Since the examiners are qualified to identify the presence of a bladder disease, their findings are credible evidence that the Veteran does not have one. Considering two examiners who evaluated the issue came to the same conclusion, their findings were assigned great weight. The Board notes that even if the Veteran had reported pain associated with urinary incontinence, the examiners did not find it impacted her ability to work. See November 2017 VA DBA at 9; October 2018 VA DBQ at 8. Thus, the record does not reflect functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). The Board recognizes the Veteran has reported she believes she has a bladder disease or disorder; however, her lay assertions are not competent evidence that could be considered on this issue. Although the Veteran is competent to report observations like urinary incontinence, whether her observations support a diagnosis of a bladder disease is a medical question she is not qualified to make. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). In this case, the evidence weighs against finding the Veteran has had a chronic bladder disease at any time during the appeal period. The Veteran's lay statements are not competent to diagnose the presence of one. In contrast, the VA examiners who prepared the November 2017 and October 2018 VA DBQs are competent to make that determination. They found the Veteran does not have a bladder disease. Since their findings were assigned great weight, doubt could not be resolved in the Veteran's favor. Gilbert, 1 Vet. App. at 54. Because the weight of the evidence does not support finding the Veteran had a chronic bladder disease during the appeal period, she has not established she has a current disability. Without a current disability she is unable to establish entitlement to service connection under 38 C.F.R. § 3.303. Holton v. Shinseki, 557 F.3d 1363, 1366-68 (Fed. Cir. 2009). The Board notes that even if the record reflected the Veteran has a chronic bladder disease during the appeal period, the evidence does not support a grant of service connection. The Board observes the Veteran's numerous visits to sick-call during service support a finding of an in-service incurrence of urinary incontinence, but the evidence weighs against finding a nexus. Although the Veteran has stated she observed urinary incontinence following service, her lay observations alone are not sufficient to establish a nexus. She is competent to report urinary leakage following service, but diagnosing a bladder disease requires medical knowledge. The record does not show she has the necessary medical training or experience to diagnose a bladder disease. So, the Veteran's statements associating her observations with a bladder disease are not competent evidence that could be considered on this issue. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). The Board recognizes her lay observations are competent to support a later diagnosis of a disability; however, the VA examiners who considered them determined a diagnosis of a bladder disease is not appropriate at this time. See November 2017 VA DBQ at 2, 6; October 2018 VA DBQ at 2, 8. Since the examiners also considered evidence of record and their personal examinations of the Veteran, the Board finds they were informed of the relevant details of the Veteran's past medical history when coming to their conclusions. Nievez-Rodriguez, 22 Vet. App. at 301. The examiner who prepared the October 2018 VA DBQ provided remarks that constitute a medical opinion. The examiner indicated she evaluated symptoms and conditions that are relevant to classifying and diagnosing a bladder disease. See VA DBQ at 8. Since the examiner is qualified to identify incontinence and opine on its presence, her explanation is sufficient for the Board to evaluate whether the data she relied on connects to her conclusion. So, the Board assigned it significant weight. Nievez-Rodriguez, 22 Vet. App. at 301. The findings in the November 2017 VA DBQ support the examiner's conclusion. The examiner who prepared the November 2017 VA DQB also concluded the Veteran's urinary incontinence is not related to a gynecological condition. Considering the examiner was aware of the Veteran's complaints of urinary incontinence during service when she made that determination, it is apparent to the Board the examiner did not see a causal connection. Even though the Veteran provided additional lay observations during her July 2019 hearing, the details she provided are not likely to have changed the examiners conclusions. During the hearing, the Veteran reiterated observations of incontinence during service. Considering her STRs include several visits to sick-call for incontinence, the Board finds her testimony was redundant of existing evidence of record. Thus, consideration of a remand for a new medical opinion was not warranted. In this case, the evidence weighs against finding a nexus. The Veteran is not competent to assert whether her observed urinary incontinence is related to her service. In contrast, the VA examiner who prepared the October 2018 medical opinion is competent to render such an opinion. She concluded the Veteran does not have a diagnosed bladder disease and her current urinary incontinence is not related to her service. Thus, even if the Veteran had established a current disability and in-service incurrence of urinary incontinence, she would not have established a nexus. In sum, the Veteran has not established she has had a chronic bladder disease during the appeal period. Even if she had, service connection on a direct basis would not be warranted because the evidence does not support finding a nexus. Accordingly, she has not established entitlement to service connection under 38 C.F.R. § 3.303. Considering she does not have a current disability, she is unable to establish to entitlement to service connection under 38 C.F.R. § 3.310. Id. So, consideration of secondary service connection is not warranted at this time. Also, the Veteran has not raised any other issues nor have any other issues been reasonably raised by the record. Robinson v. Peake, 21 Vet. App. 545, 552-54 (2008) (holding the Board is not required to address issues unless specifically raised by the claimant or reasonably raised by the record). The Board regrets a more favorable decision could not be reached in the Veteran's case. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dean, Michael S. 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.