Citation Nr: 21039658 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 16-12 987 DATE: July 1, 2021 ORDER Entitlement to service connection for erectile dysfunction secondary to the service-connected anxiety disorder associated with tinnitus is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, the probative evidence of record demonstrates that the Veteran's erectile dysfunction is due to the service-connected anxiety disorder. CONCLUSION OF LAW The criteria for service connection for erectile dysfunction, to include as secondary to the service-connected anxiety disorder, have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1967 to June 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from a December 2015 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). On the March 2016 VA Form 9, the Veteran requested the opportunity to testify before a member of the Board. A Travel Board hearing was scheduled for February 2019; however, in a January 2019 correspondence, the Veteran cancelled the scheduled hearing. Therefore, the hearing request is considered withdrawn. In February 2018, the Veteran opted into the modernized review system, also known as the Appeals Modernization Act (AMA), by submitting a Rapid Appeals Modernization Program (RAMP) election form and selecting the Higher Level Review lane. However, because VA did not process the RAMP election form prior to certifying the Veteran's appeal to the Board, the Board sought clarification from the Veteran with regard to participation in RAMP in a September 2019 letter. As the Veteran did not respond to the letter within 60 days, the Board will adjudicate the appeal under the Legacy appeals system. This issue was previously before the Board in December 2019, when it was remanded for further development. That development was completed, and the case has since been returned to the Board for appellate review. Entitlement to service connection for erectile dysfunction secondary to the service-connected anxiety disorder associated with tinnitus On their October 2015 claim, the Veteran filed for service connection for erectile dysfunction secondary to the service-connected anxiety disorder. 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, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The December 2015 and August 2020 VA examinations note a diagnosis of erectile dysfunction. Accordingly, the first element of service connection is met. Second, the Board finds that the erectile dysfunction is secondary to the service-connected anxiety disorder. In December 2015, the RO obtained a negative nexus opinion based on a review of the records. The examiner opined that there was no evidence that the erectile dysfunction is due to anxiety. The examiner explained that the Veteran had complained of low libido for several years intermittently since 2002, and that the Veteran occasionally used Viagra. The examiner stated that while several providers had mentioned low libido and erectile dysfunction, it was not mentioned when the Veteran was referred to for mental health for anxiety, or at a February 2015 complete physical. The examiner did note that June 2015 VA treatment records found that the erectile dysfunction seemed to have a psychological component, but on the corresponding disability benefits questionnaire (DBQ), the examiner explained that it was only one provider, and that it was anecdotal. The examiner reasoned that the Veteran has a significant systemic disease, including benign prostate hyperplasia, uncontrolled hypertension, chronic abdominal pain, possible irritable bowel syndrome, elevated prostate-specific antigen possibly due to chronic prostatitis, tension headaches, work stress while employed, and depression. In August 2020, the RO obtained a new VA medical opinion. On a direct basis, the examiner provided a negative nexus opinion, explaining that there is no in-service disease, event, or injury capable of resulting in erectile dysfunction. On a secondary basis, the examiner provided a positive nexus opinion, finding that it is at least as likely as not that the erectile dysfunction is caused by the service-connected anxiety disorder. The examiner explained that there is a medically documented multifactorial erectile dysfunction, attributed to anxiety, arterial insufficiency, and post-prostatectomy complete erectile dysfunction. The examiner stated that medical documentation attributes erectile dysfunction prior to November 2017 to anxiety, noting that erections were present and that erectile dysfunction medication was effective, and that after November 2017, it is attributed to a radical prostatectomy, noting that there were no erections and that medication was ineffective. When asked to opine whether the erectile dysfunction was aggravated by the service-connected anxiety disorder, the examiner noted that it was not applicable, in light of the above positive nexus opinion. On the corresponding DBQ, the examiner noted that it is at least as likely as not that the erectile dysfunction is attributable to prostate cancer. In April 2021, the Veteran submitted a private positive nexus opinion written by a practicing family physician who is also a retired United States Air Force Colonel. This examiner wrote this opinion, it appears, largely in response to the above notation from the August 2020 that the erectile dysfunction is at least as likely as not related to prostate cancer. The examiner explained that all form of treatment for prostate cancer are known to cause erectile dysfunction, including prostatectomy; however, since symptoms for erectile dysfunction predate a diagnosis and treatment for prostate cancer, the question should be whether erectile dysfunction is a common symptom of prostate cancer. Citing a study on the relation between erectile dysfunction and prostate cancer, the examiner explained that erectile dysfunction patients were only 19 percent to 27 percent more likely to have prostate cancer than patients without erectile dysfunction, depending on whether the cause of the erectile dysfunction was psychological or organic. The examiner opined that this does not meet the mathematical threshold of 50 percent used by VA for service connection. Citing WebMD, the examiner explained that prostate cancer is not often a cause of erectile dysfunction, but treatment for prostate cancer is. Regarding arterial insufficiency, the examiner explained that the only place in the record noting erectile dysfunction due to arterial insufficiency was in a problem list, and only reflects which code was selected by the staff member who added it to the list. Finally, the examiner concluded that based on the above observations, and the well-documented anxiety problem, it is at least as likely as not that the erectile dysfunction was caused by psychological factors, including anxiety disorder, and not pre-treatment prostate cancer or arterial insufficiency. The Board affords the April 2021 private medical opinion and the August 2020 VA medical opinions great probative value. Both opinions are supported by a thorough review of the medical record, and well-reasoned rationale. Additionally, the April 2021 private medical opinion cited to relevant medical literature. Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444, 448-9 (2000). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). These opinions are further bolstered by VA mental health treatment records supporting the same conclusion. June 2015 records note that there is a psychological component to the erectile dysfunction. August 2015 records note that the anxiety disorder is resulting in difficulty with ejaculation and erections. September 2015 records note that the Veteran was able to have intercourse since the last appointment, and was able to perform without issue, therefore it was clear that the erectile dysfunction is psychologically affected. March 2017 VA treatment records note that the erectile dysfunction is worse in times of stress. The Board also finds that the August 2020 note that erectile dysfunction is as likely as not due to prostate cancer is not in contradiction of the above positive medical opinions. The examiner was essentially saying that prior to the prostatectomy, the erectile dysfunction was due to anxiety, and after the prostatectomy, it was due to residuals of the prostate cancer. The Board affords December 2015 VA medical opinion less probative value. While it reflects a review of the record, the examiner erroneously stated that only one of the Veteran's physicians attributed the erectile dysfunction to anxiety; however, as noted above, the Veteran's medical records reveals at least three instances from two separate medical providers where the anxiety was noted to be related to the erectile dysfunction. A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Additionally, while the examiner opined that the service-connected anxiety disorder did not cause the erectile dysfunction, the examiner did not address whether it aggravated the erectile dysfunction. In a secondary service connection claim, a medical opinion that a disorder is not the result of an already service-connected disability does not address the issue of aggravation. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). The Board also notes that on the January 2016 notice of disagreement, the Veteran asserted that the erectile dysfunction is age-related, that medication took care of the problem, and that all men have an increase of erectile dysfunction as they age. The Veteran asserted that it is a natural process that takes place over decades and does not suddenly appear. The Veteran asserted that the erectile dysfunction is not related to hypertension. The Board notes that, while the Veteran is competent to report observable symptoms, they are not shown to possess the medical training necessary to establish a current disability or render competent opinions about the etiology of a disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Although the ability to maintain an erection is readily observable by the Veteran, attributing erectile dysfunction to the natural aging process is beyond the capabilities of a layperson. Therefore, to the extent that the Veteran attempts to establish the etiology of the erectile dysfunction, these statements are outweighed by the medical evidence of record. (Continued on the next page) Accordingly, resolving reasonable doubt in the Veteran's favor, the Board concludes that service connection for erectile dysfunction secondary to service-connected anxiety disorder has been shown. Accordingly, as the benefit-of-the-doubt rule is for application, the grant of service connection for erectile dysfunction is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rogos 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.