URINARY INCONTINENCE

TIFFANY DAWSON · 2021 · Case ID: 21002713

DENIED

Summary

The veteran served on active duty from May 1991 to May 1994. This case involves claims for service connection for bowel incontinence, urinary incontinence, and groin numbness, each sought as secondary to the veteran's service-connected back disability, specifically chronic lower back pain with degenerative arthritis and radiculopathy. The Board reviewed multiple medical opinions, including VA examinations from April 2010, May 2015, and October 2019, as well as private physician consultations and various diagnostic tests like MRIs and EMGs. The primary issue was whether the service-connected back condition caused or aggravated the claimed secondary conditions. The Board found that while the veteran had current diagnoses for these conditions and was service-connected for a back disability, the nexus element was not met. Multiple VA examiners concluded that the evidence did not establish a causal link or aggravation, citing normal MRIs, negative EMG findings for nerve impingement, age-related pelvic floor weakness, and the delayed onset of symptoms relative to the in-service injury. The Board gave probative weight to the later VA opinions, particularly the October 2019 examination, which concluded it was less likely than not that the back disability caused or aggravated the bowel incontinence, urinary incontinence, and groin numbness. The Board found the veteran's lay statements regarding etiology lacked probative value as they were not competent medical opinions. Ultimately, the Board determined the preponderance of the evidence was against the claims, denying service connection for all three conditions as secondary to the service-connected back disability.

Rationale

Preponderance of evidence against claim; Lack of nexus for causation; Lack of nexus for aggravation

Special Benefit

NO SPECIAL BENEFIT

Docket No.

11-29 938

Full Decision Text

Citation Nr: 21002713
Decision Date: 01/14/21 Archive Date: 01/14/21

DOCKET NO. 11-29 938
DATE: January 14, 2021

ORDER

Entitlement to service connection for bowel incontinence, as secondary to the Veteran’s service-connected back disability, is denied.

Entitlement to service connection for urinary incontinence, as secondary to the Veteran’s service-connected back disability with radiculopathy, is denied.

Entitlement to groin numbness, as secondary to the Veteran’s service-connected back disability with radiculopathy, is denied.

FINDINGS OF FACT

1. The Veteran’s bowel incontinence is neither proximately due to nor aggravated by her back disability.

2. The Veteran’s urinary incontinence is neither proximately due to nor aggravated by her back disability.

3. The Veteran’s groin numbness is neither proximately due to nor aggravated by her back disability.

CONCLUSIONS OF LAW

1. The criteria for service connection for bowel incontinence, as secondary to the Veteran’s service-connected back disability, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for service connection for urinary incontinence, as secondary to the Veteran’s service-connected back disability, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for service connection for groin numbness, as secondary to the Veteran’s service-connected back disability, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served honorably on active duty from May 1991 to May 1994.

This matter comes before the Board of Veterans’ Appeals (Board) from a May 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

In January 2015, the Board remanded the claims for further development, to help determine whether the Veteran’s service-connected chronic lower back pain with radiculopathy (lower back disability) aggravated her bowel incontinence, urinary incontinence, or groin numbness. Although the VA medical opinion addressed causation, it failed to address aggravation. Accordingly, the Board ordered an addendum opinion to address whether these conditions were permanently aggravated by the appellant’s service-connected low back disability.

In its March 2017 decision, the Board declined to grant service connection for bowel incontinence, urinary incontinence, and groin numbness. The Veteran appealed to the Court of Appeals for Veterans Claims (CAVC). In its June 2018 Memorandum Decision, CAVC dismissed the decision denying entitlement to an initial disability rating in excess of 40 percent for a low back disability, and entitlement to service connection on a direct basis for bowel incontinence, urinary incontinence, and groin numbness. CAVC vacated the Board’s March 2017 decision denying disability compensation for bowel incontinence, urinary incontinence, and groin numbness, each as secondary to the service-connected back disability. In January 2019, the matter was remanded by the Board for further development consistent with the Memorandum Decision. The matter has been returned to the Board for review. A review of the record shows substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board recognizes the time that the Veteran has devoted to this appeals process and appreciates her patience.

The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008).

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought);
ions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008).

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).

Establishing secondary service connection requires evidence of: (1) a current disability (for which secondary service connection is sought); (2) a service-connected disability; and (3) that the current disability was either caused or aggravated by the service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). The Court has held that entitlement to service connection on a secondary basis under a causation theory need not be service connected or diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, Vet. App. 131, 134 (2017).

The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value.

When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).

1. Entitlement to service connection for bowel incontinence, as secondary to the Veteran’s service-connected back disability.

The Veteran contends that service connection is warranted for her bowel incontinence, as secondary to her service-connected back disability. It is argued that the claimed condition has been caused or aggravated by her service-connected chronic low back pain with degenerative arthritis and radiculopathy.

The Veteran’s December 2009 Statement in Support of Claim endorsed bowel incontinence onset to be around 2009, stating, “At first it was just fecal streak in my underwear but lately the fecal matter is much worse.” A December 2009 post-service treatment record from the Veteran’s primary care provider noted episodic bowel incontinence together with flare ups of lumbar back pain. The Veteran described her incontinence symptoms together with the progression of numbness in her legs and feet. The primary care provider ordered an EMG and a neurological consultation to further evaluate these conditions. The March 2010 Neurology Consult found no neurological disorder and did not identify an etiology of the Veteran’s bowel incontinence.

In the April 2010 VA Peripheral Nerves Examination, the examiner noted the Veteran’s sensory loss of the feet and legs in the L4-L5 distributions, which was intact and evaluated in March 2010. Based on a normal MRI of the lumbar spine, which showed no evidence of compression deformity on any of the nerve roots and no impingement of the spinal nerves, the examiner determined it was less likely than not that the Veteran’s bowel incontinence was related to her low back disability. Although the April 2010 examiner opined against a causal relationship, the examiner did not address aggravation.

In an August
neurological disorder and did not identify an etiology of the Veteran’s bowel incontinence.

In an August 2010 post-service treatment record, the Veteran was seen for a Gastroenterology Consult. The physician’s assistant examining the Veteran noted that the Veteran’s rectal incontinence was slowly improving, however not completely resolved. She further noted that the etiology is not clear but there is suggestion that the Veteran has some reinnervation of muscles in the pelvic floor. Later that month, in August 2010, the Veteran was seen at an MRI clinic. The radiologist noted no detectable lesion of sacral plexus itself, dilated vascular; presumed venous structures about lower uterine segment suggesting pelvic congestion syndrome. He further noted that this impression should be correlated as a potential cause of the patient’s symptoms.

In a February 2011 post-service treatment record, the Veteran was seen for Physical Medicine Rehab Consult in which the Veteran underwent an electromyography (EMG) test. The physician noted that the Veteran had normal external anal sphincter EMG and that the etiology of the rectal incontinence is unclear.

The Veteran saw a private physician in December 2011 to further assess her fecal incontinence. The physician noted that the positional nature of her symptoms suggests the presence of dilated vasculature on her sacral MRI and the possibility of pelvic congestion syndrome. However, it “would be unlikely to cause neurology symptoms such as fecal incontinence, though a literature search will be undertaken.” The physician noted that a follow-up is required after imaging is completed.

In May 2015 the Veteran was afforded a VA Examination. The examiner was specifically instructed to address both causation and aggravation for the Veteran’s secondary service connection claim. The examiner opined that given the absence of evidence of spinal nerve compression or even significant encroachment on spinal foramina or several MRIs, the Veteran’s service connected back disability is not the proximate cause of the Veteran’s bowel incontinence. The examiner noted the Veteran had undergone EMG studies of the pelvic floor musculature which did not find evidence of spinal nerve impairment. Further, there was no additional evidence that the Veteran’s low back disability was the proximate causation of the described fecal leakage. This lack of evidence led to the conclusion that it was less likely than not that her service-connected low back disability had either caused or aggravated beyond some normal progression pelvic floor dysfunction, which was most probably attributable to age related pelvic floor relaxation. Therefore, it was less likely than not that the Veteran’s bowel incontinence was secondary to her service-connected back disability.

In October 2019, the Veteran was afforded a VA Disability Benefits Questionnaire Examination for her bowel condition. The examiner was specifically instructed to address aggravation for the Veteran’s secondary to service connection claim. The examiner was unable to determine a baseline level of severity of the claimed condition. As rationale to why a baseline cannot be established the examiner stated, “With conflicting symptoms, imaging and testing, the medical evidence is not sufficient to support a determination of a baseline level of severity.” As to the whether the Veteran’s bowel incontinence is aggravated by her service connected back disability the examiner provided a negative opinion. The examiner noted that the Veteran’s back injury was in 1992, in 2009 her bowel incontinence began, in June 2010 and January 2011 she reported no urinary or bowel incontinence, and in 2013 it was reported that her sphincter tone was normal and that the Veteran had pelvic floor weakness. The examiner concluded that “it would be expected, that if the Veteran suffered a spinal injury that resulted in bowel incontinence, the incontinence would have occurred shortly after the injury, not 17 years later.” The examiner opined that “the Veteran’s current diagnosis for bowel incontinence is less likely than not caused by/or aggravated beyond its natural progression by the Veteran’s service connected disability to include chronic low back pain with degenerative arthritis, and radiculopathy of the bilateral lower extremities.

The Board notes that direct service connection has already been adjudicated in the March 2017 Board decision. The Board found that direct service connection was not warranted
sphincter tone was normal and that the Veteran had pelvic floor weakness. The examiner concluded that “it would be expected, that if the Veteran suffered a spinal injury that resulted in bowel incontinence, the incontinence would have occurred shortly after the injury, not 17 years later.” The examiner opined that “the Veteran’s current diagnosis for bowel incontinence is less likely than not caused by/or aggravated beyond its natural progression by the Veteran’s service connected disability to include chronic low back pain with degenerative arthritis, and radiculopathy of the bilateral lower extremities.

The Board notes that direct service connection has already been adjudicated in the March 2017 Board decision. The Board found that direct service connection was not warranted because a nexus between bowel incontinence and the in-service event could not be established. CAVC dismissed direct service connection for bowel incontinence, as discussed above, thus letting the Board’s decision on this matter stand. The Board’s inquiry is to determine whether the evidence satisfies the elements required for secondary service connection.

As an initial matter, the record shows the Veteran has a current diagnosis for bowel incontinence, which she attributes to her service-connected back disability. See October 2019 Rectum and Anus Conditions Disability Benefits Questionnaire. Therefore, the current disability element is met. Further, the record shows that the Veteran is service connected for chronic low back pain with degenerative arthritis and bilateral radiculopathy. Therefore, the service-connected disability element is satisfied. Our analysis now turns on whether the final element of nexus is met.

From the outset, the Board acknowledges the Veteran’s sincere belief that her bowel incontinence is secondary to her service connected back disabilities. The Board has considered statements offered by the Veteran regarding the etiology of her bowel incontinence. However, while the Veteran is competent to report symptoms and describe observations because this requires only personal knowledge as it comes through the senses, she is not competent to make an etiological finding linking bowel incontinence to her service connected back disability because that is a complex medical question, and requires specialized training or expertise in medicine. 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). As such, her lay statements concerning etiology of her bowel incontinence lack probative value.

Regarding nexus, the Board finds very little probative value in the March 2010 Neurology Consult, August 2010 Gastroenterology Consult, February 2011 Physical Medicine Rehab Consult. These consults stated that etiology was unclear and none of these consult visits linked the Veteran’s condition to her back disability. Additionally, the December 2011 private physician speculated against the Veteran’s contention, stating that vasculature of the sacral spine and possible pelvic congestion syndrome condition would be unlikely to cause neurology symptoms such as fecal incontinence. The private physician statement of speculation is not a clear statement of opinion as to the etiology of the Veteran’s condition and is therefore given little weight.

The Board notes that although the April 2010 VA opinion was found to be inadequate by the January 2015 Board Decision, this was merely due to the failure of the examiner to address the aggravation prong that is required of secondary service connection, as opposed to a deficiency in the examiner’s rationale. The April 2010 examiner had the benefit of reviewing the Veteran’s entire claims file, including the Veteran’s STR, post-service medical evidence, medical history, and lay statements. Additionally, the examiner relied on sufficient medical facts, as well as the lay statements from the Veteran, to provide sound reasoning for his opinion on a causal relationship. For these reasons, the Board finds that the April 2010 examiner’s opinion regarding a lack of causal relationship between the Veteran’s bowel incontinence and her service-connected back disability to be probative. As such, the April 2010 exam is given some probative weight.

The Board notes that although the May 2015 VA opinion was found to be inadequate in CAVC’s Memorandum Decision, this was due to the failure of the examiner to address the aggravation prong that is required of secondary service connection, as opposed to a deficiency in the examiner’s rationale. The May 2015 examiner had the benefit of reviewing the Veteran’s entire claims file, including the Veteran’s STR, post-service medical evidence, medical history, and lay statements. Additionally, the examiner relied on sufficient facts, such as the absence of spinal nerve compression in MRIs and lack of evidence of nerve impairment in EMG studies, to provide sound reasoning for his opinion on a causal relationship.
0 exam is given some probative weight.

As for the October 2019 VA opinion, the examiner had the benefit of reviewing the Veteran’s entire claims file, including the Veteran’s STRs, post-service medical evidence, medical history, and lay statements. Additionally, the examiner relied on sufficient facts, such as the EMG testing, MRIs, and the Veteran’s medical history, to provide a sound reasoning. Additionally, this medical opinion is the most recent examination recorded of the Veteran’s condition. For these reasons, the Board finds that the examiner’s opinion, concluding that the Veteran’s bowel incontinence was not aggravated nor caused by her back disability, to be highly probative.

On the issue of aggravation, the Board interprets the October 2019 examiner’s opinion on aggravation to be two-fold. Firstly, no baseline could be determined, therefore it could not be substantiated with the medical evidence whether the Veteran’s service connected back disability aggravated her bowel incontinence. Secondly, regardless of a baseline, no aggravation of the Veteran’s condition occurred because the June 2010, January 2011, and 2013 reports showed that the Veteran’s bowel incontinence started resolving. Aggravation occurs when a condition is worsened beyond its natural progression. However, the examiner noted that the Veteran’s condition improved not worsened, therefore it was not aggravated. The October 2019 VA examiner’s opinion regarding aggravation is bolstered by December 2016 and October 2018 VA treatment records which document the Veteran denied bowel or bladder symptoms and stated she had no trouble with bowel or bladder control, respectively. Accordingly, the aggravation prong of secondary service connection has not been met.

As for causation, the October 2019 VA examiner opined that if bowel incontinence were to be caused by the Veteran’s service-connected back disability, it would have occurred at or near the onset of her back disability in 1992, and not many years later in 2009. Additionally, the May 2015 VA examiner opined that EMG testing and MRIs do not provide evidence to support a causal relationship between the Veteran’s bowel incontinence and her service-connected back disability. Accordingly, the causation prong of secondary service connection has not been met.

In sum, upon careful review and weighing of the evidence, with reasoning as detailed above, the Board finds that the preponderance of the evidence is against the claim for service connection of the Veteran’s bowel incontinence, as secondary to her service connected back disability. As the weight of the evidence is against this claim, the “benefit of the doubt” rule is not for application, and the Board must deny the claim. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. at 49.

2. Entitlement to service connection for urinary incontinence, as secondary to the Veteran’s service-connected back disability.

The Veteran contends that service connection is warranted for her urinary incontinence, as secondary to her service-connected back disability. It is argued that the claimed condition has been caused or aggravated by her service-connected chronic low back pain with degenerative arthritis and radiculopathy. The Veteran’s December 2009 Statement in Support of Claim endorsed urinary incontinence onset to be around 2009, stating, “Sometime[s] I get a dribble of urine that runs down my leg.”

In the April 2010 VA Examination, the examiner noted a normal MRI of the lumbar spine, which showed no evidence of compression deformity on any of the nerve roots and no impingement of the spinal nerves. Based on the medical evidence, the examiner concluded it was less likely than not that the Veteran’s urinary incontinence was related to her low back disability. Further, the examiner stated that the Veteran’s symptoms are more consistent with stress urinary incontin
pain with degenerative arthritis and radiculopathy. The Veteran’s December 2009 Statement in Support of Claim endorsed urinary incontinence onset to be around 2009, stating, “Sometime[s] I get a dribble of urine that runs down my leg.”

In the April 2010 VA Examination, the examiner noted a normal MRI of the lumbar spine, which showed no evidence of compression deformity on any of the nerve roots and no impingement of the spinal nerves. Based on the medical evidence, the examiner concluded it was less likely than not that the Veteran’s urinary incontinence was related to her low back disability. Further, the examiner stated that the Veteran’s symptoms are more consistent with stress urinary incontinence. Although the April 2010 examiner opined against a causal relationship, the examiner did not address aggravation.

In May 2015 the Veteran was afforded a VA Examination. The examiner was specifically instructed to address both causation and aggravation for the Veteran’s secondary service connection claims. The examiner noted that there was no evidence that compression of spinal nerve roots was the underlying cause of the cyst stress urinary incontinence. The examiner noted the Veteran had extensive evaluation to include pelvic floor muscle EMG studies that did not identify abnormalities of spinal nerve function that could reasonably be caused by the low back disability. The examiner explained that a spinal nerve injury was not a specific identified cause of stress urinary continence and that incontinence associated with spinal cord injury was typically in overflow incontinence. Further, the examiner noted that urinary incontinence is common as woman age and develop age-related pelvic floor weakness. Pregnancy and vaginal birth will aggravate and are often the underlying cause of pelvic floor relaxation and associated stress incontinence, but these conditions can occur in women who have never been pregnant or in women who have been delivered by cesarean delivery. Therefore, the examiner concluded that the Veteran’s urinary incontinence was not secondary to her service-connected low back disability.

In October 2019, the Veteran was afforded a VA Disability Benefits Questionnaire examination for Urinary Tract Conditions. The Veteran was diagnosed with urinary hesitancy. The Veteran reported to the examiner that she started having intermittent episodes of urinary hesitancy around 2009. Since then, she continues to have the inability to empty her bladder. The examiner noted that the Veteran has voiding dysfunction but that it does not cause urine leakage.

The Board notes that in the October 2019 Disability Benefits Questionnaire, the examiner linked her medical opinion for urinary incontinence together with the claim for groin numbness as “groin numbness with onset of urinary incontinence.” The examiner could not establish a baseline level of severity. The examiner noted that although the onset of the Veteran’s groin numbness with onset of urinary incontinence is mentioned in a 2010 record, there is no further documentation regarding urinary incontinence. Without such evidence the examiner stated that the medical evidence is not sufficient to support a determination of a baseline level of severity. As to whether the Veteran’s groin numbness with onset of urinary incontinence is aggravated by her back disability the examiner provided a negative opinion. The examiner noted that the Veteran’s back injury was in 1992, additionally the Veteran’s groin numbness with onset of urinary incontinence was in 2009. Additionally, the examiner states that the 2011 imaging did not find nerve impingement as a cause for numbness. The examiner further notes that, the Veteran had no paresthesias or numbness, only mild pain in the 2015 VA examination, however on this exam the Veteran had severe intermittent pain with mild paresthesias and numbness of lower extremities. The examiner concluded that, “This would give one pause regarding whether the Veteran’s current symptoms are related to her low back injury, or whether the Veteran has a separate pathology confounding her symptoms.” The examiner opined that due to absence of medical documentation of the Veteran’s progression of groin numbness with onset of urinary incontinence since 2015, it is less likely as not cause by and/or aggravated beyond its natural progression by the Veterans’ service connected back disability.

The Board notes that direct service connection has already been adjudicated in the March 2017 Board decision. The Board found that direct service connection was not warranted because a nexus between urinary incontinence and the in-service event could not be established. CAVC dismissed direct service connection for urinary incontinence, as discussed above, thus letting the Board’s decision on this matter stand. The Board’s inquiry is to determine whether the evidence satisfies the elements required for secondary service connection.

As an initial matter, the record shows the Veteran has a current diagnosis for urinary incontinence, which she attributes to her service-connected back disability. See October 2019 Disability Benefits Questionnaire for Urinary Tract Conditions. Therefore, the current disability element is met. Further, the record shows that the Veteran is service connected for chronic low back pain with degenerative arthritis and bilateral radiculopathy. Therefore, the service-connected disability element is satisfied. Our analysis now turns on whether the final element of nexus is met.

From the outset, the Board acknowledges the Veteran’s sincere belief that her urinary incontinence is secondary to her service connected back disabilities. However, while the Veteran is competent to report symptoms and describe observations because this requires only personal knowledge as it comes through the senses; she is not competent to make an etiological finding linking urinary incontinence to her service connected back disability because that is a complex medical question, and requires specialized training or expertise in medicine. See Davidson v. Shinseki, 581 F.3d at 1313; Jandreau v. Nicholson, 492 F.3d at 1372; Buchanan v. Nicholson, 451 F.3d at 1331. As such, her lay statements concerning etiology of her urinary incontinence lack probative value.

The Board notes that although the April 2010 VA opinion was found to be inadequate by the January 2015 Board Decision, this was due to the failure of the examiner to address the aggravation prong that is required of secondary service connection, as opposed to a deficiency in the examiner’s rationale. The April 2010 examiner had the benefit of reviewing the Veteran’s entire claims file, including the Veteran’s STR, post-service medical evidence, medical history, and lay statements. Additionally, the examiner relied on sufficient medical facts, as well as the lay statements from the Veteran, to provide sound reasoning for his opinion on a causal relationship. For these reasons, the Board finds that the examiner’s opinion regarding a lack of causal relationship between the Veteran’s urinary incontinence and her service-connected back disability to be probative. As such, the April 2010 exam is given some probative weight.

As for the October 2019 VA opinion, the examiner had the benefit of reviewing the Veteran’s entire claims file, including the Veteran’s STR, post-service medical evidence, medical history, and lay statements. Additionally, the examiner relied on sufficient facts, such as the EMG testing, MRIs, and the Veteran’s medical history, to provide a sound reasoning. Additionally, this medical opinion is the most recent examination recorded of the Veteran’s condition. For these reasons, the Board finds that the examiner’s opinion, concluding that the Veteran’s urinary incontinence was not aggravated nor caused by her back disability, to be highly probative.

On the issue of aggravation, the Board interprets the October 2019 examiner’s opinion to mean that her urinary incontinence was not aggravated by her back disability because although the evidence shows her back disability getting worse, her urinary incontinence started resolving. The Board notes that aggravation occurs when a condition is worsened beyond its natural progression. However, the examiner noted that the Veteran’s condition did not worsen, this was evidenced by the lack of progress notes on urinary incontinence post 2015. The October 2019 VA examiner’s opinion regarding aggravation is bolstered by December 2016 and October 2018 VA treatment records which document the Veteran denied bowel or bladder symptoms and stated she had no trouble with bowel or bladder control, respectively. Due to this, examiner concluded that her back disability does not aggravate her urinary incontinence. Accordingly, the aggravation prong of secondary service connection has not been met.

As for causation, the October 2019 VA examiner opined that the Veteran’s urinary incontinence was less likely than not caused by the service-connected back disability because the MRIs did not find nerve impingement as a cause for the Veteran’s groin numbness (with onset of urinary incontinence). Additionally, the May 2015 VA examiner opined that the Veteran’s urinary incontinence was not secondary to her service connected back disability. He stated that the EMG studies did not identify abnormal spinal nerve function to connect the Veteran’s urinary incontinence with her back disability. Furthermore, even if there was evidence of spinal nerve function, the examiner states that it could not have been the cause of stress urinary incontinence because incontinence with the spinal cord typically results in an overflow incontinence. The April 2020 VA examiner concluded that due to the lack of imaging abnormalities, the urinary incontinence is not caused by her service connected back disability. Accordingly, the causation prong of secondary service connection has not been met.

In sum, upon careful review and weighing of the evidence, with reasoning as detailed above, the Board finds that the preponderance of the evidence is against the claim for service connection of the Veteran’s urinary incontinence, as secondary to her service connected back disability. As the weight of the evidence is against this claim, the “benefit of the doubt” rule is not for application, and the Board must deny the claim. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. at 49.

3. Entitlement to service connection for groin numbness, as secondary to the Veteran’s service-connected back disability.

The Veteran contends that service connection is warranted for groin numbness, as secondary to her service-connected back disability. It is argued that the claimed condition has been caused or aggravated by her service-connected chronic low back pain with degenerative arthritis and radiculopathy. The Veteran’s December 2009 Statement in Support of Claim endorsed groin numbness onset to be around 2009, stating, “I have also noticed a numbness in my crotch area, I cannot feel when I am leaking...There is also a lack of sexual feeling in the groin.”

In the April 2010 VA Peripheral Nerves Examination, the examiner noted the Veteran’s sensory loss of the feet and legs in the L4-L5 distributions, which was intact and evaluated in March 2010. Based on a normal MRI of the lumbar spine, which showed no evidence of compression deformity on any of the nerve roots and no impingement of the spinal nerves, the examiner determined it was less likely than not that the Veteran’s groin numbness was related to her low back disability. Although the April 2010 examiner opined against a causal relationship, the examiner did not address aggravation.

In May 2015 the Veteran was afforded a VA examination. The examiner was specifically instructed to address both causation and aggravation for the Veteran’s secondary service connection claims. The examiner found that there was no evidence of spinal nerve impingement in the lumbar spinal canal to cause sacral spinal nerve dysfunction. Although the most likely explanation of the symptoms was a peripheral nerve condition, no specific named peripheral nerve condition has been stated. Therefore, the examiner concluded it was less likely than not that the Veteran’s groin numbness was secondary to her service-connected low back disability. Additionally, the examiner noted that the Veteran continued to have right sided lumbosacral radiculopathy symptoms which have been present since onset of the disorder in service, as well as intermittent left lumbosacral radicular symptoms.

The Board notes that in the October 2019 Disability Benefits Questionnaire, the examiner linked her medical opinion for urinary incontinence together with the claim for groin numbness as “groin numbness with onset of urinary incontinence.” The examiner could not establish a baseline level of severity. The examiner noted that although the onset of the Veteran’s groin numbness with onset of urinary incontinence is mentioned in a 2010 record, there is no further documentation regarding urinary incontinence. Without such evidence the examiner stated that the medical evidence is not sufficient to support a determination of a baseline level of severity. As to whether the Veteran’s groin numbness with onset of urinary incontinence is aggravated by her back disability the examiner provided a negative opinion. The examiner noted that the Veteran’s back injury was in 1992, additionally the Veteran’s groin numbness with onset of urinary incontinence was in 2009. Additionally, the examiner states that the 2011 imaging did not find nerve impingement as a cause for
examiner noted that although the onset of the Veteran’s groin numbness with onset of urinary incontinence is mentioned in a 2010 record, there is no further documentation regarding urinary incontinence. Without such evidence the examiner stated that the medical evidence is not sufficient to support a determination of a baseline level of severity. As to whether the Veteran’s groin numbness with onset of urinary incontinence is aggravated by her back disability the examiner provided a negative opinion. The examiner noted that the Veteran’s back injury was in 1992, additionally the Veteran’s groin numbness with onset of urinary incontinence was in 2009. Additionally, the examiner states that the 2011 imaging did not find nerve impingement as a cause for numbness. The examiner further notes that, the Veteran had no paresthesias or numbness, only mild pain in the 2015 VA examination, however on this exam the Veteran had severe intermittent pain with mild paresthesias and numbness of lower extremities. The examiner concluded that, “This would give one pause regarding whether the Veteran’s current symptoms are related to her low back injury, or whether the Veteran has a separate pathology confounding her symptoms.” The examiner opined that due to absence of medical documentation of the Veteran’s progression of groin numbness with onset of urinary incontinence since 2015, it is less likely as not cause by and/or aggravated beyond its natural progression by the Veterans’ service connected back disability

The Board notes that direct service connection has already been adjudicated in the March 2017 Board decision. The Board found that direct service connection was not warranted because a nexus between groin numbness and the in-service event could not be established. CAVC dismissed direct service connection for groin numbness, as discussed above, thus letting the Board’s decision on this matter stand. The Board’s inquiry is to determine whether the evidence satisfies the elements required for secondary service connection.

As an initial matter, the record shows the Veteran has a current diagnosis for groin numbness, which she attributes to her service-connected back disability. See October 2019 Peripheral Nerves Conditions Disability Benefits Questionnaire. Therefore, the current disability element is met. Further, the record shows that the Veteran is service connected for chronic low back pain with degenerative arthritis and bilateral radiculopathy. Therefore, the service-connected disability element is satisfied. Our analysis now turns on whether the final element of nexus is met.

From the outset, the Board acknowledges the Veteran’s sincere belief that her groin numbness is secondary to her service connected back disabilities. The Board has considered statements offered by the Veteran regarding the etiology of her condition. However, while the Veteran is competent to report symptoms and describe observations because this requires only personal knowledge as it comes through the senses; she is not competent to make an etiological finding linking groin numbness to her service connected back disability because that is a complex medical question, and requires specialized training or expertise in medicine. See Davidson v. Shinseki, 581 F.3d at 1313; Jandreau v. Nicholson, 492 F.3d at 1372; Buchanan v. Nicholson, 451 F.3d at 1331. As such, her lay statements concerning etiology of her groin numbness lack probative value.

The Board notes that although the April 2010 VA opinion was found to be inadequate by January 2015 Board Decision, this was due to the failure of the examiner to address the aggravation prong that is required of secondary service connection, as oppose to a deficiency in the examiner’s rationale. The April 2010 examiner had the benefit of reviewing the Veteran’s entire claims file, including the Veteran’s STR, post-service medical evidence, medical history, and lay statements. Additionally, the examiner relied on sufficient medical facts, as well as the lay statements from the Veteran, to provide sound reasoning for his opinion on a causal relationship. For these reasons, the Board finds that the examiner’s opinion regarding a lack of causal relationship between the Veteran’s groin numbness and her service-connected back disability to be probative. As such, the April 2010 exam is given some probative weight.

The Board notes that although the May 2015 VA opinion was found to be inadequate in CAVC’s Memorandum Decision, this was due to the failure of the examiner to address the aggravation prong that is required of secondary service connection, as oppose to a deficiency in the examiner’s rationale. The May 2015 examiner had the benefit of reviewing the Veteran’s entire claims file, including the Veteran’s STR, post-service medical evidence, medical history, and lay statements. Additionally, the examiner relied on sufficient facts, such as the absence of spinal nerve compression in MRIs and lack of evidence of nerve impairment in EMG studies, to provide sound reasoning for his opinion on a causal relationship. For
exam is given some probative weight.

The Board notes that although the May 2015 VA opinion was found to be inadequate in CAVC’s Memorandum Decision, this was due to the failure of the examiner to address the aggravation prong that is required of secondary service connection, as oppose to a deficiency in the examiner’s rationale. The May 2015 examiner had the benefit of reviewing the Veteran’s entire claims file, including the Veteran’s STR, post-service medical evidence, medical history, and lay statements. Additionally, the examiner relied on sufficient facts, such as the absence of spinal nerve compression in MRIs and lack of evidence of nerve impairment in EMG studies, to provide sound reasoning for his opinion on a causal relationship. For these reasons, the Board finds that the examiner’s opinion regarding a lack of causal relationship between the Veteran’s groin numbness and her service-connected back disability to be probative. As such, the May 2015 exam is given some probative weight.

As for the October 2019 VA opinion, the examiner had the benefit of reviewing the Veteran’s entire claims file, including the Veteran’s STR, post-service medical evidence, medical history, and lay statements. Additionally, the examiner relied on sufficient facts, such as the EMG testing, MRIs, and the Veteran’s medical history, to provide a sound reasoning. Additionally, this medical opinion is the most recent examination recorded of the Veteran’s condition. For these reasons, the Board finds that the examiner’s opinion, concluding that the Veteran’s groin numbness was not aggravated nor caused by her back disability, to be highly probative.

On the issue of aggravation, the Board interprets the October 2019 examiner’s opinion to mean that her groin numbness was not aggravated by her back disability because although the evidence shows her back disability as severe, her groin numbness did not change. The Board notes that aggravation occurs when a condition is worsened beyond its natural progression. However, the examiner noted that the Veteran’s condition did not worsen when her radiculopathy worsened, this was evidenced by the lack of progress notes on groin numbness post 2015. Due to this, examiner concluded that her back disability does not aggravate her groin numbness. Accordingly, the aggravation prong of secondary service connection has not been met.

As for causation, the October 2019 VA examiner opined that the Veteran’s groin numbness was less likely than not caused by the service-connected back disability because the MRIs did not find nerve impingement as a cause for the Veteran’s groin numbness. Additionally, the May 2015 VA examiner opined that the Veteran’s groin numbness was not secondary to her service connected back disability. He stated that the EMG studies did not identify abnormal spinal nerve function to connect the Veteran’s groin numbness with her back disability. Due to the lack of imaging abnormalities, the April 2010 VA examiner concluded that groin numbness is not caused by her service connected back disability. Accordingly, the causation prong of secondary service connection has not been met.

In sum, upon careful review and weighing of the evidence, with reasoning as detailed above, the Board finds that the preponderance of the evidence is against the claim for service connection of the Veteran’s groin numbness, as secondary to her service connected back disability. As the weight of the evidence is against this claim, the “benefit of the doubt” rule is not for application, and the Board must deny the claim. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. at 49.

Tiffany Dawson

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board N. Jamordee

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.

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