Citation Nr: 22014343 Decision Date: 03/12/22 Archive Date: 03/12/22 DOCKET NO. 16-19 697 DATE: March 12, 2022 ORDER Entitlement to service connection for a bladder disorder, to include as secondary to service-connected diabetes mellitus, type II is denied. FINDING OF FACT The Veteran's bladder disorder is not shown to be etiologically related to service or to have been caused or aggravated by the Veteran's service-connected diabetes mellitus, type II including medications taken for the treatment of diabetes mellitus, type II. CONCLUSION OF LAW The criteria for service connection for a bladder disorder, to include as secondary to a service-connected diabetes mellitus, type II, including medications taken for the treatment of diabetes mellitus, type II, 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 active duty in the United States Army from May 1968 to November 1970, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in August 2019. A transcript is of record. The Board previously remanded this claim in December 2019 and July 2021 for additional development. As the actions specified in the remand have been substantially completed, this matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Duties to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A; 38 C.F.R. § 3.159. The Veteran has not advanced any procedural arguments in relation to VA's duty to notify and assist; therefore, the Board will proceed with appellate review. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). 1. Entitlement to service connection for a bladder disorder, to include as secondary to service-connected diabetes mellitus, type II Generally, to establish service connection 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." Davidson v. Shinseki, 581 F.3d 1313, 131516 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated (worsened) by a service-connected disability. Id. The Veteran contends that his bladder disorder is etiologically related to service. Specifically, he argues that his bladder disorder is caused or aggravated by his service-connected diabetes mellitus, type II, to include as due to the medication he takes to treat and manage his diabetes mellitus, type II. As noted above, the first element of service connection requires medical evidence of a present disability VA treatment records show that the Veteran has been diagnosed with a bladder disorder and has had urinary problems, including incontinence, frequent urination, and bladder elimination. Thus, the issue before the Board is whether the Veteran's bladder disorder had its onset during service or is otherwise etiologically related to any in-service illness, injury, or event. The Veteran's service treatment records have been associated with the claims file. They are silent for complaint, treatment, or diagnosis of any injury effecting the bladder during service. At both his August 1977 enlistment examination and May 1980 separation examination, the Veteran denied a history of urinary problems. Based on the evidence of record, there is no probative and competent evidence that demonstrates an in-service occurrence of bladder disorder during active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(d). In fact, the Veteran has not asserted direct service connection and has not provided lay evidence in support of this theory. In sum, the Board finds that the evidentiary record does not contain an in-service occurrence to establish that the second criterion to establish service connection on a direct basis has been met. Next, the Board considers whether service connection is warranted for a bladder disorder on a secondary basis. The Veteran underwent an examination in February 2016 to determine the nature and etiology of his bladder disorder. On examination, the examiner confirmed a diagnosis of benign prostatic hyperplasia (BPH) and voiding dysfunction. The Veteran reported that he began experiencing trouble with his bladder in 2013 and underwent a transurethral resection (TURP) procedure of the prostate in December 2015, and since his surgical intervention he had a great deal of relief and he has not needed to catharize since surgery. In a July 2019 statement, K.A., a registered nurse, stated that the medication he requires for his diabetes has impacted his bowel and bladder function. Side effects from these medications now have made him fear anytime away from immediate access to toilets. Diapers have become a staple. During his August 2019 hearing, the Veteran testified that his diabetes is the cause for his bladder disability. Accordingly, on remand, the Board requested an addendum opinion concerning direct and secondary service connection in February 2020. In February 2020, after a thorough review of the Veteran's entire claims file, a VA examiner opined that the Veteran's bladder disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness or was less likely as not caused by the service-connected diabetes mellitus. The VA examiner concluded that the Veteran's urinary condition and bladder obstruction was due to benign prostatic hyperplasia (BPH), or an enlarged prostate, which was diagnosed in 2013, well after his separation from service. The examiner further noted that the VA treatment showed the Veteran underwent a TURP in 2015 that resolved the Veteran's bladder issue. Based on this evidence, he opined that a secondary nexus was not established. The examiner further stated there is no evidence of aggravation. In August 2021, an addendum opinion was obtained in which the VA examiner opined it is not likely that a bladder disorder was either caused by or aggravated by the Veteran's service-connected diabetes mellitus, including medications taken to treat and manage this condition. The examiner noted consideration of the July 2019 statement from K.A., R.N, regarding the medication impact on the Veteran's bladder function. The VA examiner noted that the statement is vague and does not say which drug is supposed to do this and a rationale. He furthered that such a nexus is not supported by peer reviewed medical literature. The VA examiner noted the medications the Veteran was prescribed for treatment of his diabetes mellitus. The VA examiner opined that none of the drugs the Veteran is prescribed are known to cause a bladder dysfunction. He concluded that the Veteran's bladder issues are related to his prostate condition. Based on a careful review of the subjective and clinical evidence, the Board finds that the evidence persuasively weighs against finding service connection for a bladder disorder is warranted, to include as secondary to the Veteran's service-connected diabetes mellitus, type II and the medications the Veteran takes to manage and treat the service-connected condition. The Veteran has asserted that his bladder disorder is due to his service-connected diabetes mellitus. VA treatment records show that he has been diagnosed with a bladder disorder and had urinary problems, including frequent urination or bladder elimination. However, a review of a VA examinations related to the Veteran's service-connected diabetes mellitus do not indicate a bladder disorder as a complication of his condition. See February 2016 and September 2019 VA examinations. Moreover, VA examinations related to the claim do not provide a positive opinion relating the bladder condition to his service-connected diabetes. In February 2020, the VA examiner opined that it is less likely than not the bladder disorder was incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted the Veteran's diagnosed bladder disorder, bladder obstruction, was due to an enlarged prostate. He indicated that the enlarged prostate was diagnosed in 2013, well after his separation from service. More recently, the August 2021 VA examiner opined that it is not likely that a bladder disorder was either caused by or aggravated by the Veteran's service-connected diabetes mellitus, including medications taken to treat and manage the diabetes mellitus. The August 2021 VA examiner also opined that the Veteran's bladder issues are related to his prostate condition. The February 2020 and August 2021 opinions are supported by well-reasoned rationales which discussed the Veteran's reported history with bladder dysfunction, identified another more likely cause for the bladder condition, and directly cited to medical evidence of record. The August 2021 VA examiner noted a review of medical literature that did not support the Veteran's contentions. As such, the Board finds that the VA opinions are entitled to significant probative weight as to the presence of a nexus. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The examining medical providers had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data, noting that the August 2021 VA examiner considered the specific medications that the Veteran took for treatment of his diabetes mellitus. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). In making this determination, the Board acknowledges that the July 2019 VA opinion is favorable to the Veteran's claim, however as the private R.N. provided an insufficient rationale, as noted in the August 2021 VA addendum opinion, not indicating which medication in particular she contended was causing or aggravating the Veteran's bladder conditions nor did she provide citations to medical literature to support her conclusion. To have probative value, a medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Therefore, the July 2019 private opinion holds minimal probative weight. Conversely, the Board finds the August 2021 examiner's opinion to be highly probative as to the question of whether any of the medication the Veteran takes to manage and treat his service-connected diabetes mellitus, type II caused or aggravated his bladder condition. In this regard, the opinion is based on application of current medical principles and the examiner's own expertise as a physician to the facts of the Veteran's case and the examiner provided a clear, well-reasoned medical rationale to support his conclusion that is consistent with the evidence of record and was responsive to each question posed in the Board's remand directives. See Nieves-Rodriguez, 22 Vet. App. at 295; see also Prejean v. West, 13 Vet. App. 444 (2000); Guerrieri v. Brown, 4 Vet. App. 467 (1993). The Board further acknowledges the Veteran's belief that his current disability should be service connected. The Veteran is competent to report on matters observed or within his personal knowledge and is therefore competent to make statements regarding his symptoms and medical history. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, a probative medical opinion on the etiology or underlying causes of his bladder disorder requires the specialized training of a medical professional. In this case, as a layperson not shown to possess appropriate medical training and expertise, the Veteran is not competent to render a persuasive or competent medical opinion on whether his bilateral knee disability was incurred in or caused by his military service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir 2006). Therefore, any opinion by the Veteran regarding the etiology of his disability is not competent evidence. The Board finds the VA medical opinions of record, provided by qualified medical professionals, to be more probative in regard to causation. Based on the foregoing and after careful review of the subjective and clinical evidence of record, the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for a bladder disorder, to include as secondary to service-connected diabetes mellitus, type II is warranted. Rather, the evidence persuasively weighs against a finding that service connection for a bladder disorder, to include as secondary to service-connected diabetes mellitus, type II and the medications the Veteran takes to manage his service-connected diabetes mellitus, type II is warranted. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to this claim. Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir. Dec. 17, 2021) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application). LESLEY A. REIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Rosenthal, Ariana 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.