Citation Nr: 23006025 Decision Date: 01/31/23 Archive Date: 01/31/23 DOCKET NO. 18-38 224 DATE: January 31, 2023 ORDER Entitlement to service connection for erectile dysfunction is granted. FINDING OF FACT The evidence is in relative equipoise as to whether the Veteran's erectile dysfunction is caused or aggravated by his service-connected posttraumatic stress disorder (PTSD), to include the medications he takes for management of his PTSD symptoms. CONCLUSION OF LAW The criteria for entitlement to service connection for erectile dysfunction have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on multiple periods of active duty, to include from June 1992 to August 1992, from March 2003 to March 2005, from March 2005 to September 2005, from January 2006 to June 2006, from June 2006 to October 2006, from November 2006 to March 2007, from April 2010 to November 2010, and from February 2012 to December 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2017 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). 1. Entitlement to service connection for erectile dysfunction is granted. The Veteran contends that his erectile dysfunction is related to his service-PTSD. Specifically, the Veteran asserts that the medications he takes for his service-connected PTSD can cause or aggravate his current erectile dysfunction. See November 2016 Fully Developed Claim (Compensation) (VA 21-526EZ). Establishing service connection generally requires competent evidence of (1) a current disability; (2) 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); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection may also be granted on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b) (2017); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). To establish entitlement to service connection on a secondary basis, there must be evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. In this case, service connection for PTSD was established in a November 2013 rating decision. A February 2017 VA examination report reflects that the Veteran is diagnosed with erectile dysfunction. Therefore, the issue is whether there is a causal relationship between the Veteran's erectile dysfunction and his service-connected PTSD. The Veteran underwent a VA male reproductive system conditions examination in February 2017. Regarding etiology of the Veteran's erectile dysfunction, the February 2017 VA examiner opined that it is most likely the result of the Veteran's hypogonadism. The VA examiner opined that the Veteran's erectile dysfunction is less likely than not proximately due to or the result of the Veteran's service-connected PTSD. The examiner reasoned that "[the Veteran] reports PTSD, intermittently problematic, with nightmares and stress, treated with Trazodone and Sertraline. These medicines can cause delayed orgasm but are not strong causative agents for erectile dysfunction. PTSD is a stronger causative agent if considered directly, however, even in this case, hypogonadism is a far stronger and more dependable cause. Further, the onset of erectile dysfunction and low testosterone at the same time makes it most likely that these conditions are causally related." The Veteran submitted an opinion from a private treatment provider in August 2017. The private treatment provider stated that the Veteran has been a patient since September 2015. The private treatment provider noted that the Veteran's past medical history is significant for PTSD, male hypogonadism, and male erectile dysfunction. The private treatment provider stated, "[the Veteran's] PTSD is currently being managed with Sertraline and Trazadone. Both of these medications have the potential to cause sexual dysfunction as an adverse side effect. [The Veteran's] low testosterone level would certainly result in male erectile dysfunction. This condition is being corrected with testosterone replacement therapy. His erectile dysfunction could likely be aggravated by the use of the previously mentioned medications for PTSD." An addendum VA opinion was obtained in August 2017. The August 2017 VA examiner opined that the Veteran's erectile dysfunction is not at least as likely as not aggravated beyond its natural progression by his service-connected PTSD. The VA examiner reasoned that there is "[n]o objective medical record evidence to indicate otherwise was found. VA treatment center medication list indicated that the Veteran is no longer on testosterone replacement therapy; this along with his current testosterone level is unclear. Nevertheless, the Veteran has multiple risk factors for aggravation of erectile dysfunction, to include obesity. Though various things can cause erectile dysfunction, there's a consistently strong connection between obesity and sexual dysfunction - obese men are 2 12 times more likely to experience erectile dysfunction than those of normal weight. Of note, medications can produce temporary, but not permanent aggravation, as there is no mechanism for permanent aggravation." The Board finds the August 2017 opinion from the private physician to be highly probative. The probative value of medical opinion evidence is based on his or her knowledge and skill in analyzing the data and the medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the private physician provided an adequate explanation as to why the Veteran's erectile dysfunction was secondary to his service-connected PTSD. He explained that the erectile dysfunction can be aggravated and/or caused by both of the medications that the Veteran has been taking regularly for his service-connected PTSD. While it is not clear that the physician reviewed the entire claims file, an examiner needs only be informed of the sufficient relevant facts so as to be able to form an appropriate medical opinion, as evidenced in this case. See Nieves-Rodriguez, 22 Vet. App. 295 (2008). For instance, the physician noted that the Veteran was undergoing multiple medical problems under his care. On the other hand, the Board finds that the medical opinion provided by the VA examiner in February 2017 is not probative. Notably, the February 2017 VA opinion addressing the theory of secondary service connection is inadequate because the VA examiner did not address whether the Veteran's erectile dysfunction is aggravated by his service-connected PTSD. See El-Amin v. Shinseki, 26 Vet. App. 136 (2013) (holding that medical opinion that only addresses whether a service-connected disability caused a nonservice-connected disability does not address whether the service-connected disability aggravated a nonservice-connected disability). Therefore, the Board finds this opinion is not probative on the issue of whether a nexus exists between the Veteran's current erectile dysfunction and his service-connected PTSD. However, the Board finds that the August 2017 VA examiner's opinion is also probative, in that it is based on accurate facts, and provides the underlying reasons for the conclusions reached. Although the August 2017 VA examiner opined that the Veteran's other risk factors affected the Veteran's erectile dysfunction, the private physician who was also aware of the Veteran's other medical problems opined that the Veteran's erectile dysfunction was secondary to his service-connected PTSD, to include the medications taken for treatment. Pursuant to the "benefit-of-the-doubt" rule, where there is "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. 38 U.S.C. § 5107. Therefore, the Board finds that the Veteran's erectile dysfunction must be attributed to his service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (noting that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so); see also Howell v. Nicholson, 19 Vet. App. 535, 540 (2006) (where there is a lack of sufficient medical evidence that differentiates such symptoms, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability). As the record reflects that the (1) Veteran is service connected for PTSD, (2) the Veteran is diagnosed with erectile dysfunction, and (3) there is a sound medical opinion relating the Veteran's erectile dysfunction to his service-connected PTSD, the Board finds that resolving all doubt in the Veteran's favor, service connection for erectile dysfunction has been established. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. M. Lowman, Associate Counsel 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.