Citation Nr: 21030827 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-11 500 DATE: May 19, 2021 ORDER Entitlement to service connection for erectile dysfunction (ED) as secondary to service-connected disabilities is denied. FINDING OF FACT The probative evidence does not establish that the Veteran's erectile dysfunction is etiologically related to his service-connected disabilities. CONCLUSION OF LAW The criteria for entitlement to service connection for erectile dysfunction as secondary to service-connected disabilities have not been 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 in the United States Army from June 1972 until June 1975. This matter was initially before the Board in May 2020, where it was remanded for additional development. Specifically, the Board determined that the Veteran should be afforded an additional examination to determine the nature and etiology of his erectile dysfunction. The matter returned to the Board in February 2021, where it was remanded for additional development. The Board determined that there has not been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Such development has been completed and the matter returned to the Board for appellate consideration. Entitlement to service connection for ED as secondary to service-connected disabilities. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis. In this instance, the evidence must demonstrate an etiological relationship between a service-connected disability or disabilities on the one hand and the condition said to be proximately due to the service-connected disability or disabilities on the other. 38 C.F.R. § 3.310(a); Wallin v. West, 11 Vet. App. 509 (1998). Medical evidence is required to demonstrate a relationship between a current disability and the continuity of symptomatology demonstrated if the condition is not one where a lay person's observations would be competent. Clyburn v. West, 12 Vet. App. 296 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was noted during service; (2) evidence of post-service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Evidence of a chronic condition must be medical, unless it relates to a condition to which lay observation is competent. Savage v. Gober, 10 Vet. App. 488 (1997). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Turning to the evidence, service treatment records are silent for any complaints, treatments, or manifestations of erectile dysfunction. Upon discharge, the Veteran's clinical evaluation of relevant systems were clinically normal. According to the medical evidence of record, the earliest diagnosis of erectile dysfunction was in 2004, see November 2016 VA examination, which was approximately 29 years since service. The Veteran was afforded a VA examination in December 2013. The examiner opined that his ED is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected diabetes and/or lumbar degenerative disc and joint disease. The examiner reasoned that a review of his medical records indicates "multiple lifestyle choices and comorbid condition known to contribute to ED in this Veteran." He added that the Veteran had low testosterone treated with testosterone injections, a long history of alcohol abuse, and tobacco abuse. The Veteran was afforded a second VA examination in November 2016. He reports that his ED has been problematic since 2004. The examiner opined that his ED is less likely than not proximately due to or the result of the Veteran's service-connected diabetes. The examiner reasoned that treatment records indicate that his ED preceded his service-connected diabetes, which had its onset in October 2011. According to the Veteran's 2006 medical records, his ED has been problematic for years. The examiner also opined that the etiology of his ED is "most likely due to his long-standing hypertension," which he is not service-connected for. The Veteran was afforded a third VA examination in November 2020, where the examiner opined that his ED is less likely than not proximately due to or the result of his service-connected conditions. The examiner reasoned that his erectile dysfunction began many years prior to his diagnosis of diabetes. Although the Veteran stated that he has been experiencing diabetic-like symptoms since 2003, "his HbA1C level on 1/18/2011 was 6.1, which is normal [and] his HbA1C level did not become elevated until October 2011." Similarly, the examiner opined that his ED preceded his 2013 myeloma diagnosis. Regarding his service-connected PTSD, the examiner stated that during his April 2011 PTSD exam, he denied any erectile dysfunction and denied taking any medication for treatment of PTSD. The examiner also opined that there is insufficient evidence in the Veteran's medical records to indicate there was any aggravation of the erectile dysfunction. "PCP note dated 1/30/2006 noted the [V]eteran complaining of erectile dysfunction and was prescribed Viagra. However, since then, the [V]eteran had no further complaints of erectile dysfunction." Lastly, the examiner opined that his longstanding history of uncontrolled hypertension is known to cause erectile dysfunction. In a March 2021 VA addendum opinion, the examiner opined that the Veteran's ED is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. He also opined that his ED is less likely than not proximately due to or the result of his service-connected diabetes, multiple myeloma, renal insufficiency, and lumbar spine disability with right lower extremity sciatica including medications taken for such disorders. Similar to prior examinations, the examiner reasoned that his ED preceded his diagnosis of diabetes, myeloma, and renal insufficiency. Additionally, the examiner also reasoned that his ED is likely due to his uncontrolled hypertension. Regarding his service-connected renal insufficiency and lumbar spine disability, the examiner stated that there is no medical evidence to suggest that renal insufficiency and lumbar degenerative disc disease and joint disease with interverbal syndrome or any medications associated with these conditions, cause erectile dysfunction. The examiner also added that the Veteran's service-connected disabilities did not cause a functional impairment associated with ED, as there is "no evidence in the [V]eteran's medical records of any increase in disability or symptoms." Lastly, the examiner opined that while uncontrolled diabetes mellitus can lead to a worsening of ED, this was not the case in the instant matter. Relevant treatment records indicate that the Veteran's diabetes was controlled throughout the period on appeal, confirming the examiner's rationale. See e.g., August 2013 VA Treatment Record; July 2019 VA Treatment Record. Further, while the Veteran contends that he had diabetes-like symptoms prior to his diagnosis of ED, the Veteran is not competent to render a medical opinion in his case. A trained VA examiner considered the Veteran's theory specifically reviewing the Veteran's historical HbA1C levels. Additionally, according to a December 2004 VA treatment record, the Veteran denied a significant history of diabetes mellitus. The Board affords this statement significant probative weight as it was made to a medical examiner in the context of seeking appropriate medical evaluation since service. See generally Lilly's An Introduction to the Law of Evidence, 2nd Ed. (1987), pp. 245- 46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). The Board acknowledges that there were times during the period on appeal where the Veteran's glucose levels were higher than normal. See e.g., July 2005 VA Treatment Record. Further, there are discrepancies as to when the Veteran was diagnosed with diabetes. For example, in a June 2006 private treatment record, his treating physician stated that his diabetes mellitus is manageable by restricted diet only and he currently has no complications that are directly related to diabetes mellitus. However, the Veteran's physician did not mark off his initials where it states that the Veteran has been diagnosed with diabetes mellitus II. Instead, the physician added a notation, stating "he has mild impairment of fasting glucose by 7/2005 labs." Conversely, in a June 2006 treatment record, the Veteran's physician stated that the Veteran is not diabetic. Therefore, even assuming arguendo that the Veteran was diagnosed with diabetes in June 2006, the Veteran's ED diagnosis would have still preceded his diagnosis of diabetes. Upon review of the medical and lay evidence, the Board finds that the probative evidence of record is against the claim, and service connection for ED on a direct basis, secondary basis, or presumptive basis is not warranted. The most competent and credible evidence of record shows that there is no causal or aggravation basis between the Veteran's ED and his service-connected disabilities, nor is there a causal or aggravation basis for an additional functional impairment due to his service-connected disabilities. In rendering this decision, the Board has considered the Veteran's lay statements and notes that he is competent to report his symptoms and the circumstances surrounding his ED. Although lay persons are competent to provide opinions on observable lay symptoms or conditions, the specific issue in this case, the etiology of erectile dysfunction, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (explaining in footnote 4 that a Veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Overall, the Board finds that the opinion of the VA examinations is probative and persuasive as to the etiology of the Veteran's erectile dysfunction. The expert medical opinions were prepared by a skilled, neutral medical professional after review of the claims file and previous examinations of the Veteran. Furthermore, it is supported by a complete rationale. The Veteran has not provided a favorable medical opinion to the contrary to weigh in this matter. Accordingly, the preponderance of the evidence is against the claim, and entitlement to service connection for erectile dysfunction is denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 49. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Adeleke, T. 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.