Citation Nr: 21041440 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 10-00 155 DATE: July 9, 2021 ORDER Entitlement to service connection for recurrent urinary tract infection (UTI), to include as secondary to service-connected conditions, including right testicle atrophy, is denied. FINDINGS OF FACT 1. The weight of the medical and other evidence of record is against a finding that the Veteran has a recurrent UTI condition, claimed as urinary tract infection, that had its onset in service or is otherwise related to a disease or injury, including right testicle atrophy, during military service. 2. A UTI condition, claimed as urinary tract infection, was not manifest to a compensable degree within one year of separation from active duty service and is not otherwise related to military service. CONCLUSION OF LAW The criteria for entitlement to service connection for recurrent UTI have not been met. 38 U.S.C. §§ 101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310, 4.115b, diagnostic code (DC) 7599. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the U.S. Army from October 1981 to March 1990. This matter comes to the Board of Veterans' Appeals (Board) on appeal from May 2009 and July 2011 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. As noted in the May 2013 Board decision, it was clear from the Veteran's June 2009 notice of disagreement (See June 2009 Veteran Correspondence, "Notice of Disagreement to Decision 2...urinary tract infection") and May 2012 Board hearing (See May 2012 Board Central Office hearing transcript, "also up under that (Special Monthly Compensation) was with the urinary tract infection") that the issue of service connection for a urinary tract infection was implied in the November 2008 claim for increase of right testicle atrophy. See May 2013 BVA Decision. In May 2012, the Veteran testified before a since retired Veterans Law Judge at a Board Central Office hearing in Washington, DC. A copy of the transcript is associated with the claims file. Despite having a representative, the Veteran was not represented at the May 2012 hearing. Given the opportunity to reschedule or to proceed without representation, the Veteran elected to proceed at the hearing without representation. See May 2012 Board Central Office hearing transcript. Because the law requires that a Veterans Law Judge who conducts a hearing to participate in any decision made on that appeal, the Veteran was provided an opportunity to testify a second time. See August 2016 VA Correspondence ("You have the right to request another optional Board hearing."). The Veteran appeared at a Travel Board hearing in January 2017 before the undersigned Veterans Law Judge. A transcript of the hearing is made a part of the record. The matter was remanded in May 2013 for the RO to issue a Statement of the Case. See May 2013 BVA Decision. The matter was remanded again in October 2017 for a VA examination "to determine the nature and possible causes for the (Veteran's) claimed UTIs." See October 2017 BVA Decision. The matter was remanded a third time in May 2019 for a VA examination to "address the fact that the Veteran has been prescribed antibiotics" for a UTI. See May 2019 BVA Decision. The matter was remanded a fourth time in April 2020 for a VA examination "to consider the Veteran's lay statements that he experienced recurrent UTIs since service." See April 2020 BVA Decision. The matter was remanded a fifth time in January 2021 for a VA examination "to consider all of the relevant evidence of record." See January 2021 BVA Decision. The matter is returned to the Board for further consideration. This case has been advanced on the docket pursuant to 38 U.S.C. § 7107(b) and 38 C.F.R. § 20.902(c). 1. Entitlement to service connection for recurrent urinary tract infection The Veteran contends that he "had a urinary tract infection with that as well while on active duty" and "[has] it recurring about twice a year." See January 2017 Travel Board hearing transcript. Duty to Notify and Assist Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). VA must notify the claimant of any information, including any medical or lay evidence, not previously provided to VA, that is necessary to substantiate the claim. See 38 U.S.C. § 5103 (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). VA has satisfied its duties to inform the Veteran in this case. See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 21.1032(a). The duty to notify was satisfied by VCAA / DTA Letters dated December 2008, February and September 2009, October 2010, and June 2014. See also July 2011 VA Notification Letter, December 2014 Statement of the Case, August 2016 VA Correspondence, November 2018 Supplemental Statement of the Case (SSOC), March 2019 SSOC, January 2020 SSOC, August 2020 SSOC, January 2021 VA Subsequent Development Letter, February 2021 VA Subsequent Development Letter, March 2021 VA Subsequent Development Letter, April 2021 SSOC, and April 2021 VA Subsequent Development Letter. VA's duty to assist functions to aid a claimant in obtaining evidence necessary to substantiate a claim, but VA is not required to provide assistance to a claimant when there is no reasonable possibility that assistance would aid in substantiating the claim. See 38 U.S.C. § 5103A (2012). As for VA's assistance to the Veteran, the entire record was available to the April 2009, December 2010, February 2018, February 2019, December 2019, July 2020, and March 2021 medical examiners, Genitourinary, Male Reproductive Organ Conditions, and Urinary Tract Conditions examinations were performed, and the testing was sufficient to adequately address all potential rating criteria. See 38 U.S.C. § 7104(d)(1); 38 C.F.R. §§ 3.385, 4.87. Any reported defects in the February 2019, December 2019, or July 2020 examinations were cured by the March 2021 VA examination. See March 2021 VA examination reports. The Board finds that VA has done everything reasonably possible under 38 C.F.R. § 21.1032(a) to assist the Veteran. The Veteran has not identified any available, outstanding records that are relevant to the claim decided herein, nor is there an indication that any outstanding evidence, relevant to the claim, needs to be obtained. See June and September 2014 VCAA Notice Acknowledgement ("I have enclosed all the remaining information or evidence that will support my claim, or I have no other information or evidence to give VA to support my claim.") and January 2021 VA Subsequent Development Letter ("If you received treatment from a facility other than a local VA Medical Center that has records that need to be obtained that you feel may affect your claimed disabilities on appeal [sic] then please follow the guidance below."). Neither the Veteran nor his representative have submitted additional evidence since the April 2021 SSOC. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2017). Further development and further assistance by VA are not warranted. The RO's efforts have substantially complied with the instructions contained in the March 2013, October 2017, May 2019, April 2020, and January 2021 Board remands. See Stegall v. West, 11 Vet. App. 268 (1998). An additional remand for further development of this claim would serve no useful purpose. Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claim in this Board decision. Service Connection Generally, to prevail on a claim service connection, there must be competent and credible evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the in-service disease or injury. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. See generally 38 C.F.R. § § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Presumptive service connection can satisfy both the elements of an in-service event and a nexus to military service. Chronic diseases listed under 38 C.F.R. § 3.309(a) that manifest either during active service or to a compensable degree within the applicable time limits of 38 C.F.R. § 3.307(a) are sufficient to establish in-service incurrence or aggravation. If a chronic disease enumerated in 38 C.F.R. § 3.309(a) does not manifest in-service or within the applicable time limits, service connection may be granted based on continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Presumptive service connection can also be granted for those diseases listed under 38 C.F.R. § 3.309(b)-(f). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the credibility of lay evidence may not be refuted solely by the absence of corroborating medical evidence, it is a factor. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay evidence concerning continuity of symptoms after service, if credible, may be competent, regardless of the lack of contemporaneous medical evidence). Other factors are the lapse of time in recollecting events attested to, prior conflicting statements as opposed to consistency with other statements and evidence, internal consistency, facial plausibility, bias, interest, the length of time between alleged incurrence of disability and the earliest or first corroborating medical or lay evidence thereof, and statements given during treatment (which are usually given greater probative weight, particularly if close in time to the onset thereof). The Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). Although the Veteran is competent to provide a diagnosis of an observable condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of diseases of the genitourinary system. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104 (a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2017). Factual Background During his August 1981 service entry physical, the Veteran had a "Normal" clinical evaluation, including "G-U System." At the time, the Veteran reported, "I'm in good health," and he indicated "[n]o [f]requent or painful urination" and "[n]o [k]idney stone or blood in urine." See August 1981 Reports of Medical Examination and Medical History. In early June 1982, the Veteran reported to sick call with the following documentation: "sudden onset of (right) testicular pain this AM at 0630-0700. Pain is very severe. Tense (right) scrotal contents. Poss(ible) torsion (right) testis. (Physical exam): Globus major of right epididymis is tender & swollen. Imp(ression): Right epididymitis. Rec(ommend): Admit." See June 1982 Standard Form 513, Clinical Record. Notes from the June 1982 hospitalization include: "right intrascrotal pain which became increasingly more severe...Globus major of the right epididymis is tender and swollen...Urine cultures were sterile...Urinalysis was normal...On the second day of hospitalization, the area of swelling and tenderness of the globus major of the right epididymis was noted to have extended to the entire body of the right epididymis, excluding the globus minor. At this time, the right testicle was noted to be tense. It was speculated that the edema and inflammation of the right epididymis may have caused jeopardy to the vascular supply of the right testicle...The patient gradually improved, and on the patient's 7th day of hospitalization, he was found to be asymptomatic and without tenderness." See June 1982 Standard Form 502, Narrative Summary. March 1983 follow-up treatment documented: "Right epididymitis of globus major for which he was hospitalized in June '82...current (complaint of) right intra scrotal pain with strenuous physical activity. (Physical Examination)...Left intra-scrotal contents normal. Right gonad is high in right scrotum, 12 the size of left and of firmer consistency than left. Impression: Right testicular atrophy, post epididymitis." See March 1983 Urology Clinic, Ireland Army Hospital Chronological Record of Medical Care. March 1985 in-service treatment recorded: "24 (year old) (complains of) hit in groin while playing basketball one week ago. Normal examination excepting (right) testicular atrophy from torsion testicle 1982." See March 1985 Chronological Record of Medical Care. The Veteran waived his right to a service separation medical examination by executing the following statement, "I do not desire a separation medical examination." Information on the waiver form included the statement, "(separation medical examinations) are not accomplished to determine eligibility for physical disability processing, although such could occur as a result of examination findings." See December 1989 Statement of Option Medical Examination for Separation. At an April 2009 VA medical examination, the Veteran was interviewed, and the examiner considered his statements. The Veteran complained of atrophy of the right testicle and intermittent pain. He denied urinary flow problems, incontinence, and urinary tract infections. Further, the Veteran denied any functional impact on his daily living. The examiner diagnosed the Veteran with total atrophy of the right testis with residual erectile dysfunction and pain. See April 2009 VA Genitourinary Conditions examination. As requested by the Veteran, his primary care physician authored a letter in June 2009. It began, "Letter written as requested by patient for service connection." The letter documented "[a]trophy of the right testicle epididymitis and the urinary tract infection [sic]." The letter elaborated that the Veteran was "currently being treated for rectal dysfunction UTI." In addition, the letter stated that the Veteran was "unable to have erections." See June 2009 VA Primary Care Physician Note. A second VA examination with the Veteran was completed in December 2010. The examiner reviewed the records and considered the statements of the Veteran, who denied pain and described UTI "approximately once a year." The Veteran denied prior hospitalization for UTI and stated that his right testicle "became atrophied over time" due to an in-service injury in 1982. See December 2010 VA Genitourinary C & P Examination Note. An evaluation in September 2017 was "Negative" for genitourinary conditions. See September 2017 VA Pact Provider and Primary Care Physician Notes. Following an October 2017 appointment for "Left ankle" and "bilateral knee pain," the Veteran was prescribed "[S]eptra...for UTI." Following the prescription, a "urinalysis" was ordered. See October 2017 VA Primary Care Physician Note and VA Primary Care Physician Note Addendum. The resulting urine culture was negative for UTI. See October 2017 VA Bacteriology Final Report and December 2017 VA Urology Consult. Three weeks later and without a documented basis, a second round of antibiotics was "prescribed for recurrent UTI." See November 2017 VA Pact Provider Note Addendum. The Veteran was provided with a third VA examination in February 2018. The Veteran was evaluated in person, and his statements were considered by the examiner. As reported by the Veteran, his right testicle was injured in 1982 while "running PT at Ft. Knox, Kentucky," and he was hospitalized "for the right epididymitis." The Veteran's right testicle "atrophied and went away" over time. Renal dysfunction, voiding dysfunction, retrograde ejaculation, chronic epididymitis, epididymo-orchitis, prostatitis, neoplasms, other pertinent physical findings, complications, conditions, signs, or symptoms related to his condition, and a functional impact on his ability to work were denied by the Veteran. See February 2018 VA Male Reproductive Organ Conditions examination report. Following a "fitting of amplification recommended for management of unilateral sensorineural hearing loss," the Veteran was prescribed "bactrim bid x 14 days for UTI." No precipitating documentation appeared in the record prior to the order for antibiotics. See May 2018 VA Audiology Hearing Aid Orientation Addendum. The Veteran denied "urinary changes" to the Emergency Department in July 2018. See July 2018 VA Emergency Department Note. When asked to describe "serious and recurring illnesses" during a January 2019 Social Security Administration interview, the Veteran listed: "Left ear deafness (diagnosed in 1990), degenerative disc disease; surgery in both knees (most recent occurred in 2008), gout in his knees and ankles (diagnosed in 2012), and hypertension (diagnosed in 1982)." The Veteran also mentioned a "sleep apnea machine," a "traumatic brain injury" from playing basketball, and "chronic eye pain." See January 2019 SSA Psychological Evaluation. A urinalysis taken pursuant to a February 2019 VA examination was negative for UTI. The Veteran was provided a fourth in-person VA examination in February 2019 "to determine the nature and possible causes for his claimed UTIs." See October 2017 BVA Decision. The examiner reviewed the claims file and considered the statements of the Veteran, including sworn testimony that he experienced two UTIs per year. Noted in the examiner's report was a "4/10/2009" physical examination which documented a negative history of UTIs. The examiner concluded that there is no diagnosis of UTI because there was no pathology to render a diagnosis. See February 2019 VA Urinary Tract Conditions examination report. The February 2019 examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Next, the examiner concluded that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected conditions. Finally, the examiner concluded that the Veteran's UTI was not aggravated beyond its natural progression by his service-connected testicular atrophy with erectile dysfunction. The rationale in formulating his opinion was the absence of treatment for a UTI associated with recurrent epididymitis in service. Also, the examiner stated that there was no evidence that erectile dysfunction and right testicle atrophy led to UTIs. Based on the lack of objective treatment data, the examiner could not make an association between the Veteran's epididymitis and UTI. See February 2019 VA Urinary Tract Conditions examination report. The Veteran was diagnosed with hematuria after labs found blood in his urine in February and July 2019. See July 2019 VA Primary Care Letter. In August 2019, the Veteran reported "a history of 'prostate bleeding,'" and the endocrinologist noted the previous history of hematuria. The Veteran denied "any other complaints." See August 2019 VA Specialty Care Endocrine Note. See also November and December 2019 VA Pact OEF / OIF / OND Provider Notes ("Denies chest pain, (shortness of breath), nausea, vomiting, diarrhea, constipation, hematochezia, melena or urinary complaint.") and December 2019 VA Nursing Note ("NO IDENTIFIED GENITOURINARY PROBLEMS [sic]...Patient denies complication."). The Board determined that the February 2019 VA examination was inadequate because "[i]t did not address the fact that the Veteran has been prescribed antibiotics for his recurrent UTIs as late as November 2017." See May 2019 BVA Decision. A fifth in-person examination was performed in December 2019. The examiner reviewed the claims file and considered the statements of the Veteran, including testicular torsion and epididymitis in 1982. The Veteran reported the onset of symptoms in 1997 or 1998 when he "experienced a burning sensation on his penis," had hematuria, and was diagnosed with UTI. The Veteran stated that he received antibiotics for the UTI. Also, the Veteran stated that he has "UTIs about 3 times a year," with a burning sensation in his lower abdomen and associated hematuria. See December 2019 VA Urinary Tract Conditions examination report. The December 2019 examiner opined that the Veteran's condition was less likely than not related to service because, "there is no documentation in the available medical records that the [V]eteran had UTI during of [sic] the time (of military service)." Regarding secondary service connection, the examiner opined that the Veteran's condition was less likely than not proximately due to or the result of Veteran's service-connected conditions. Rationale included, "[T]here is not enough evidence or literature to say that the [V]eteran's UTI is connected to atrophy of right testicle with residual ED and epididymitis." Regarding aggravation, the examiner opined that the Veteran's condition was not aggravated beyond its natural progression by a service-connected condition. See December 2019 VA Urinary Tract Conditions examination report. The Veteran denied "chest pain, (shortness of breath), nausea, vomiting, diarrhea, constipation, hematochezia, melena or urinary complaint" in April 2020. See April 2020 VA Primary Care Telephone Encounter Note. The Board determined that the December 2019 VA examination was inadequate because it "failed to consider the medical evidence of record documenting the Veteran's recurrent UTIs." See April 2020 BVA Decision. An additional examination was scheduled for July 2020. The COVID pandemic prevented an in-person examination, and the Veteran was not available by telephone to answer questions from the examiner. The claims file and evidence of record was reviewed in preparation for the report. The examiner noted the Veteran's reports of UTI onset in 1982, with intermittent UTIs diagnosed over the years. See July 2020 VA Urinary Tract Conditions examination report. The July 2020 examiner concluded: "No diagnosis is warranted. [T]here is no medical evidence of chronic or recurrent UTI. Veteran has had acute UTIs in the past that resolved with antibiotics...Veteran has had UTI 2009, 2010 and 2017 which were acute. There is no medical evidence of recurrent UTI. (November) 2017 PCM note states recurrent UTI and urology notes did not diagnose recurrent / chronic UTI. Urology notes 2008 silent for UTI concerns. Medical literature does not support testicle atrophy or epididymitis as causing UTI. (Claims) file silent for chronic / recurrent UTI since separation from service. Veteran testimony he has 2 UTIs that are treated per year but medical evidence does not support this. Veteran can report symptoms but is not qualified to ascribe symptoms to a diagnosis. Urinary tract infections typically occur when bacteria enter the urinary tract through the urethra and begin to multiply in the bladder. Although the urinary system is designed to keep out such microscopic invaders, these defenses sometimes fail. When that happens, bacteria may take hold and grow into a full-blown infection in the urinary tract. [M]ayoclinic.org." See July 2020 VA Urinary Tract Conditions examination report. Regarding service connection, the July 2020 examiner opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Regarding secondary service connection, the examiner opined that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected condition. Additional rationale included: "The conditions of chronic UTI and testicle atrophy / epididymitis are not medically related. The chronic UTI is a separate entity entirely from the testicle atrophy / epididymitis and unrelated to it. A thorough review of medical literature failed to demonstrate a causal relationship. A nexus has not been established." Regarding aggravation, the examiner opined that the Veteran's claimed condition / diagnosis was not aggravated beyond its natural progression by service-connected conditions. See July 2020 VA Urinary Tract Conditions examination report. The Board determined that the July 2020 examination was inadequate, because "it did not consider / was unable to consider all of the relevant evidence of record." See January 2021 BVA Decision. Additional medical opinions were requested for the Veteran in March 2021. The examiner reviewed the claims file and associated evidence in preparation for her opinions. First, the examiner excluded the Veteran's obesity as an intermediate cause of any UTI condition and determined that the Veteran's obesity was not due to any of the Veteran's service-connected conditions or medications for service-connected conditions. The examiner reasoned, "Obesity is caused by an increased caloric intake and decreased expenditure. None of his (service-connected) conditions or medications caused an increase in calories and did not preclude him from all forms of exercise." See March 2021 VA medical examination reports. Next, the March 2021 examiner explained UTIs as "bacteria in the urinary tract," and noted that conditions, including atrophy of a testicle, do "not cause (or) aggravate bacteria in the urinary tract." The examiner then opined that the claimed UTI condition was less likely than not proximately due to or the result of the Veteran's service-connected left ear hearing loss, tinnitus, microscopic hematuria, urinary hesitancy, prostatic urethra trauma, alcohol abuse, sleep apnea, right testicle atrophy, erectile dysfunction, or allergic rhinitis conditions. In addition, the examiner opined that the Veteran's claimed condition was not aggravated by his service-connected left ear hearing loss, tinnitus, microscopic hematuria, urinary hesitancy, prostatic urethra trauma, alcohol abuse, sleep apnea, right testicle atrophy, erectile dysfunction, or allergic rhinitis conditions. Rationale in formulating her opinion included the fact that UTIs and the Veteran's service-connected conditions "are not medically related." In addition, the examiner stated, "None of the Veteran's (service-connected) conditions cause UTIs... Review of current medical literature does not support a relationship." See March 2021 VA medical examination reports. The March 2021 VA examiner continued: "A (diagnosis) of chronic UTI is not warranted...he does not have a history of chronic UTI's, and a (diagnosis) of acute UTIs is also debatable...while Veteran on occasion would report UTI symptoms, his (primary care physician) would treat (Veteran) with an antibiotic without confirmation of UTI by culture. Review of the file did not provide one positive urine culture. A UTI (diagnosis) cannot be made on symptoms alone and cannot be made on a[n] asymptomatic positive urine culture. UTIs in men are not common and often are a cause of an underlying condition, which was not identified in Veteran's (claims) file. Nonetheless, even with Veteran's noted treatment with antibiotics for 'suspected' UTIs, there is still not enough documentation of chronic UTIs which would be a considered diagnosis after three to four positive UTIs a year." See March 2021 VA medical examination reports. The March 2021 examiner concluded: "The (diagnosis) of voided urine (cystopins) with rare urothelial cells was a test being done due to Veteran's hematuria. It was not a urine culture, and the reason for the test was to find atypical cells. This was not done due to inflammation. No known cause for the inflammation but not specific to UTIs. The non-distended bladder during ultrasound is not of significance, as the Veteran's bladder was not full during the examination. This is a typical finding in someone who was not told to drink fluids prior to evaluation. The numerous documentations regarding UTIs is not supported by frequent urine culture or frequent antibiotics usage. Again, chronic UTIs (diagnosis) is not supported by lack of evidence in file. A UTI is not based on subjective complaints, as it is (diagnosed) based on objective findings. This is not supported in the (claims) file. The report of discoloration of the urine is non-specific and does not signify a UTI. The(re) is insufficient evidence to support a (diagnosis) associated with 'leaking valve' in penis. NO [sic] evidence of urinary incontinence or urinary frequency." See March 2021 VA medical examination reports. Analysis Contemporaneous medical evidence has greater probative value than the Veteran's reports of history. See Curry v. Brown, 7 Vet. App. 59 (1994). Despite the Veteran's sworn testimony on two occasions, the Veteran did not have a UTI while in the hospital in June 1982. See May 2012 Board Central Office hearing transcript ("I know I originally had the urinary tract infection when I initially had the right epididymitis.") and January 2017 Travel Board hearing transcript ("I had a urinary tract infection with that as well while on active duty...(Ireland Army Hospital) just put (me) there due to a urinary tract infection"). As documented in the treatment records from the hospital, "Urine cultures were sterile...Urinalysis was normal." See June 1982 Standard Form 502, Narrative Summary. The term "recurrent UTI" is found in a November 2017 treatment record for the Veteran. See November 2017 VA Pact Provider Note Addendum ("[P]lease make Vet(eran) aware that he needs to pick up antibiotics at Pharmacy window that I prescribed for recurrent UTI."). However, treatment records for the Veteran do not include "recurrent UTI" among "Active problems." See November 2020 VA Polytrauma Telephone Encounter Note ("1. Sensorineural hearing loss, asymmetrical. 2. Subjective tinnitus. 3. Sensorineural hearing loss, unilateral. 4. Disability examination. 5. Other examination of ears and hearing. 6. Hypertension. 7. Gout. 8. Gastroesophageal reflux disease. 9. Alcohol abuse. 10. Cocaine abuse. 11. Bilateral knee pain. 12. Pain of left ankle joint. 13. Prediabetes. 14. Homeless. 15. Hematuria. 16. Chronic post-traumatic stress disorder."). While the Veteran has been diagnosed with right testicle atrophy (See March 1983 Urology Clinic, Ireland Army Hospital Chronological Record of Medical Care), epididymitis (See June 1982 Urology Clinic, Ireland Army Hospital Note), hematuria (See July 2019 VA Primary Care Letter), and erectile dysfunction (See June 2009 VA Urology Outpatient Note), he has not been clinically diagnosed with chronic UTI. The Veteran's statements, "I do have (UTI) recurring about twice a year (See January 2017 Travel Board hearing transcript)," and "UTIs about 3 times a year (See December 2019 VA Urinary Tract Conditions examination report)" are not supported by the medical evidence of record. Assuming arguendo that the Board considered the use of the term "recurrent UTI," after a negative urine culture, as a diagnosis, the second element of service connection, an in-service event, is based upon the argument that the Veteran developed a UTI in service due to "torsion" of his right testicle. See May 2012 Board Central Office hearing transcript ("I originally had the urinary tract infection when I initially had the right epididymitis."). As noted by the March 2021 VA examiner, evidence of a UTI is based on a positive urine culture. See March 2021 VA medical examination reports. The record clearly demonstrates that the Veteran did not have a UTI in June 1982, "Urine cultures were sterile...Urinalysis was normal." See June 1982 Standard Form 502, Narrative Summary. The contemporaneous medical evidence of record excludes the possibility of the in-service event provided under oath by the Veteran. In addition to lacking a diagnosis in service, the Veteran's reports of continuity of symptomatology are based on prescriptions for antibiotics and not objective medical criteria. The Veteran denied a history of urinary tract infections at an April 2009 VA examination. See April 2009 VA Genitourinary Conditions examination report. A June 2009 letter from the Veteran's primary care physician stated, "has a urinary tract infection [sic] receiving medication." There is no underlying basis in the available records for the application of "medication" for a UTI. See June 2009 VA Primary Care Physician Note. In fact, June 2009 treatment records indicated that the Veteran was "seen...for erectile dysfunction." See June 2009 VA Urology Outpatient Note. An October 2017 urinalysis detected a "trace" of bacteria. See October 2017 VA Primary Care Physician Note ("Most recent lab results...urine bacteria: Trace."). The Veteran was prescribed "[S]eptra...for UTI." See October 2017 VA Primary Care Physician Note Addendum. A urine culture requested by the prescribing nurse practitioner four days later yielded "NO GROWTH [sic]." See October 2017 VA Bacteriology Final Report and December 2017 VA Urology Consult. The record documented no complaints or symptoms from the Veteran in either October or November 2017 regarding a UTI. In October 2017, the Veteran was seen for "Left ankle pain, and bilateral knee pain." See October 2017 VA Primary Care Physician Note. Two treatment addendums to the October 2017 primary care appointment ordered antibiotic prescriptions for "UTI," and the second round was prescribed after a urine culture ruled out UTI. See November 2017 VA Pact Provider Note Addendum ("[P]lease make Vet(eran) aware that he needs to pick up antibiotics at Pharmacy window that I prescribed for recurrent UTI."). The same pattern is documented after a May 2018 audiology appointment. While the Veteran appeared "for fitting of amplification recommended for management of unilateral sensorineural hearing loss," the record was silent for complaints or symptoms of a UTI. See May 2018 VA Audiology Hearing Aid Orientation. However, an addendum to the audiology appointment prescribed "bactrim bid x 14 days for UTI." See May 2018 VA Audiology Hearing Aid Orientation Addendum. The Veteran denied "urinary changes" in the VA Emergency Department two months later. See July 2018 VA Emergency Department Note. With issues of diagnosis and an in-service event, including chronicity and continuity of symptomatology, the Veteran is also lacking evidence of a nexus or link between any in-service event and his current medical condition. Numerous VA medical examinations were performed on the Veteran to determine the nature and etiology of any genitourinary condition, including April 2009, December 2010, February 2018, February 2019, December 2019, July 2020, and March 2021. No VA examiner was able to attribute the Veteran's acute UTI symptoms to his military service. See April 2009 and December 2010 Genitourinary Conditions, February 2018 Male Reproductive Organ Conditions, February and December 2019 and July 2020 Urinary Tract Conditions, and March 2021 examination reports. The Veteran's own primary care physician could not provide a nexus statement or opinion regarding service and UTI when asked to provide a "Letter...for service connection." See June 2009 VA Primary Care Physician Note. A urinary tract infection is not included in the list of chronic diseases enumerated in 38 C.F.R. § 3.309(a). Further, the first recorded mention of a UTI is a June 2009 "[l]etter written as requested by patient," more than 19 years after service. See June 2009 VA Primary Care Physician Note. The Veteran does not meet the requirements for presumptive service connection, either by diagnosis in-service, within the prescribed time limits after service, or through continuity of symptomatology, and he is not entitled to the presumption of an in-service incurrence, aggravation in-service, or nexus to service. Conclusion The Board has considered the Veteran's assertions that his UTI-related symptoms are caused by or related to an in-service injury. See Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, the Board finds that the reasoned opinion of a medical professional is more probative than the Veteran's lay assertions. Medical treatment staff and VA examiners have expertise, education, and training that the Veteran is not shown to have. The Veteran is not qualified to determine the nature or etiology of any genitourinary disorder he experiences. The Veteran is competent to report on factual matters of which he has firsthand knowledge, e.g., symptoms of pain in the lower abdomen. The Board has not overlooked the Veteran's statements regarding the severity of his condition. The Veteran provided lay evidence through VA treatment, VA examinations, and hearing testimony throughout the course of his appeal with respect to the presence of UTI-related symptoms. However, where the disability Rating Schedule is concerned, the criteria set forth therein generally require medical expertise where the types of findings required are not readily observable by a lay person. The April 2009, December 2010, February 2018, February 2019, December 2019, July 2020, and March 2021 opinions from the VA examiners are the most probative evidence of record on the questions of diagnosis and nexus to service and, along with the contemporaneous medical evidence, including negative UTI cultures, are accorded greater weight. The medical opinions were based on an extensive review of all of the evidence, including lay statements from the Veteran, were supported by a detailed rationale, provided data to support any conclusions, and they provided a clear and reasoned analysis, the source of the most probative value in a medical opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The April 2009, December 2010, February 2018, February 2019, December 2019, July 2020, and March 2021 VA medical opinions are consistent with one another and with the evidence of record, including the lack of urine culture evidence in both June 1982 and October 2017 to support a diagnosis of UTI. The VA medical opinions provide compelling evidence against the Veteran's claim for service connection. The Veteran contends that his claimed disabilities are related to his active service. This opinion is of no probative value because he lacks the medical expertise needed to attribute his UTI-related symptoms to active military service. There is no competent, credible evidence to refute the April 2009, December 2010, February 2018, February 2019, December 2019, July 2020, and March 2021 medical opinions. The June 2009 letter from the Veteran's primary care physician could not provide an opinion endorsing service connection, and the record does not contain any such evidence in favor of service connection. The Veteran is not entitled to a presumption of service connection through diagnosis in service, diagnosis within the prescribed time limits after service, or through continuity of symptomatology. The weight of the probative evidence of record is against a finding that the Veteran's symptoms are causally or etiologically related to any disease, injury, or incident, in service. Consequently, service connection is not warranted. In sum, a clear preponderance of the evidence of record is against the Veteran's claim for service connection of a UTI condition, and his claim must be denied. The benefit-of-the-doubt rule does not apply when the Board finds that a preponderance of the evidence is against the claim, Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Small, Attorney Advisor 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.