ERECTILE DYSFUNCTION

Summary

The veteran, who served from March 1976 to March 1980, appeals the denial of service connection for erectile dysfunction. The veteran claims the condition is secondary to his service-connected depressive disorder and migraines, including medication side effects. The Board reviewed extensive prior remands and VA examinations concerning this claim. The initial VA examination in January 2016 found erectile dysfunction less likely than not related to service-connected depression, citing the condition's onset before depression and multifactorial causes. Subsequent examinations in May 2019 and August 2019 also found the condition less likely than not related to service-connected depression or migraines, noting the condition predated depression treatment and lacked evidence of aggravation. A June 2022 remand led to a July 2023 VA addendum opinion, which the Board found highly persuasive. This opinion concluded it was less likely than not that erectile dysfunction was proximately due to or aggravated by migraines or depression, citing a lack of established causal relationship in literature and no supporting subjective complaints or objective findings of aggravation. The Board gave great weight to this opinion, noting it was consistent with the record and based on medical knowledge. The Board also considered lay statements from the veteran but found them not competent to establish medical nexus. The Board concluded the competent medical evidence, particularly the July 2023 opinion, weighed against the claim, rendering the benefit-of-the-doubt rule inapplicable. Service connection for erectile dysfunction was denied.

Rationale

Weight of competent medical evidence weighs against claim; July 2023 VA opinion found erectile dysfunction less likely than not due to or aggravated by service-connected migraines or depression; Veteran's lay opinion on etiology not competent

Full Decision Text

Citation Nr: 24022481
Decision Date: 06/06/24	Archive Date: 06/06/24

DOCKET NO. 16-15 770
DATE: June 6, 2024

ORDER

Service connection for erectile dysfunction is denied.

FINDING OF FACT

The weight of the competent evidence does not show that the Veteran's current erectile dysfunction disability was incurred during or as a result of active service, to include as proximately due or aggravated by the Veteran's service-connected disabilities.

CONCLUSION OF LAW

The criteria for entitlement to service connection for erectile dysfunction are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from March 1976 to March 1980. This matter is before the Board of Veterans' Appeals (Board) on appeal from a February 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

This appeal has a long procedural history and has been before the Board previously. To assist with adjudication of the matter listed above, the Board will provide a brief, historical summary. In September 2018, the Board remanded the issue on appeal for the agency of original jurisdiction (AOJ) to obtain a VA addendum opinion that addresses whether erectile dysfunction is aggravated by a service-connected disability. After this remand, VA obtained a medical examination in May 2019 and addendum opinion in August 2019. However, in August 2020, the Board remanded the issue on appeal for the AOJ to obtain a VA addendum opinion that addresses whether erectile dysfunction is proximately due or aggravated by his service-connected migraines. After this remand, VA obtained a medical examination in August 2020 and in March 2021, the Board denied entitlement to service connection for erectile dysfunction. The Veteran appealed the March 2021 Board decision to the United States Court of Appeals for Veteran's Claims (Court). In February 2022, the Court issued a Joint Motion for Partial Remand (JMPR). In the JMPR, the parties agreed that remand was warranted because the Board relied on an inadequate VA opinion to deny the claim that did not identify which medications the Veteran takes for his migraines. The Court granted the JMPR in a February 2022 Order, vacated the portion of the Board's March 2021decision denying entitlement to service connection for erectile dysfunction, and remanded the appeal back to the Board for further consideration. After that, in June 2022, the Board remanded the issue on appeal in accordance with the JMPR. In November 2022, the Board once again remanded the issue on appeal for the AOJ to obtain an addendum opinion that addresses a possible interaction between the Veteran's erectile dysfunction and diazepam or Valium. Furthermore, in June 2023, the Board remanded the issue on appeal for the AOJ to obtain an addendum opinion that addresses whether it is at least as likely as not that the severity of the Veteran's erectile dysfunction was aggravated since he had to stop taking the erectile dysfunction medication, Sildenafil, due to his service-connected headaches. Subsequently, after a February 2024 supplemental statement of the case considered the record, this matter has now returned to the Board for appellate consideration. The Board finds there has been substantial compliance with the prior Board remand directives as the AOJ obtained the requested VA addendum medical opinion. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Stegall v. West, 11 Vet. App. 268, 271 (1998).

The Board notes that additional VA-generated evidence was added to the record since the latest February 2024 supplemental statement of the case. However, the Board finds that it need not delay adjudication of the appeal to obtain a waiver or remand the appeal for AOJ review of this evidence because it is not pertinent to the claim on appeal. 38 C.F.R. § 19.31.

Service Connection

Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all the evidence, including that pertinent to service, establishes it was incurred in active service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.30(d). Service connection requires evidence showing: (1) the existence of a present disability;
 for AOJ review of this evidence because it is not pertinent to the claim on appeal. 38 C.F.R. § 19.31.

Service Connection

Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all the evidence, including that pertinent to service, establishes it was incurred in active service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.30(d). Service connection requires evidence showing: (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 disability incurred or aggravated by service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Regulations provide that service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439, 449 (1995); 38 C.F.R. § 3.310(b). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; (3) medical evidence establishing a nexus between the service-connected disability and the current disability.  See Wallin v. West, 11 Vet. App. 509, 512 (1998).

The Veteran is competent to report symptoms and experiences observable by his senses. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). In relevant part, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009).

Service connection for erectile dysfunction.

The Veteran contends entitlement to service connection for erectile dysfunction. Specifically, the Veteran reported that his disability is due to his service-connected depressive disorder and migraine disability, to include the medication used to treat the disabilities. See 4/10/2015 VA 21-526b; see also 11/25/2015 VA 21-526b. In this regard, the Veteran submitted a medical article purporting to demonstrate a relationship between the medications used to treat his service-connected disabilities and the claimed erectile dysfunction. See 5/31/2019 Third Party Correspondence.

At the outset, the Board notes that the record does not reflect-nor does the Veteran contend-that his erectile dysfunction onset in service or is otherwise related to an in-service event, illness, or injury. Accordingly, further discussion of the claim for service connection for erectile dysfunction on a direct basis is not warranted.

With respect to secondary service connection, following service, VA treatment records reflect assessment of erectile dysfunction. See 5/21/2014 CAPRI at page 432. The Board will now analyze whether service connection is warranted by analyzing the second and third elements of service connection.

As to the second element of service connection, service connection is in effect for migraines and depressive disorder. Thus, a claim for secondary service connection is applicable and the second Wallin element is met.

The question before the Board therefore becomes whether there is a so-called "nexus" between the Veteran's current erectile dysfunction and the service-connected disabilities.

Turning to the competent and relevant medical evidence, during the January 2016 VA examination, the Veteran was diagnosed with erectile dysfunction. At the conclusion of the examination, the examiner opined that erectile dysfunction is less likely than not proximately due to or the result of the Veteran's service-connected depression disorder. As rationale, the examiner noted an onset of erectile dysfunction in 2005, responsive to the medical Sildenafil, and discontinued secondary to headaches. He was restarted on Tadalafil and remained on Tadalafil since 2013. VA records also note impression of depression in 2013, symptoms of which the Veteran reported began in 2010. He was treated initially with Mirtazapine and then Citalopram and Fluoxetine. The examiner indicated that, to date, there was no study or evidence to related depression as a cause of
 diagnosed with erectile dysfunction. At the conclusion of the examination, the examiner opined that erectile dysfunction is less likely than not proximately due to or the result of the Veteran's service-connected depression disorder. As rationale, the examiner noted an onset of erectile dysfunction in 2005, responsive to the medical Sildenafil, and discontinued secondary to headaches. He was restarted on Tadalafil and remained on Tadalafil since 2013. VA records also note impression of depression in 2013, symptoms of which the Veteran reported began in 2010. He was treated initially with Mirtazapine and then Citalopram and Fluoxetine. The examiner indicated that, to date, there was no study or evidence to related depression as a cause of inability to have an erection. While some medication may cause a decline in libido, the Veteran had good libido with normal testosterone levels. Moreover, his erectile dysfunction preceded his depression diagnosis. The examiner concluded that the Veteran's erectile dysfunction etiology was probably multifactorial with factors, such as changes in overall health, daily life stress and situations, relationships, adverse personal lifestyle choices, poor or lacking physical fitness, and aging. See 1/30/2016 C&P Examination. However, in September 2018, the Board found this examination inadequate to decide the claim. The examiner only discussed causation by his service-connected depression disorder but did not discuss aggravation by the service-connected depression disorder. However, a secondary service connection claim has two prongs: causation and aggravation. 38 C.F.R. § 3.310. To be adequate, a VA opinion must provide separate rationales for both causation and aggravation. See Atencio v. O'Rourke, 30 Vet. App. 74, 90 (2018) (citing El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013)).

As per the September 2018 Board remand directives, the Veteran underwent another VA examination in May 2019. At the conclusion of the examination, the examiner opined that erectile dysfunction is less likely than not caused or aggravated by the Veteran's service-connected depression or incurred during service. As rationale, the examiner stated that the Veteran had erectile dysfunction after service and before his depression. See 5/23/2019 C&P Examination.

Additionally, in August 2019, the May 2019 examiner provided an addendum opinion. The May 2019 examiner opined that erectile dysfunction is less likely than not proximately due to, the result of, or aggravated by any of the Veteran's service-connected disabilities, including aggravation due to an inability to take proper medications. As rationale, the examiner stated that the Veteran had erectile dysfunction after service but before his depression and that he found no evidence of aggravation in the record. See 8/12/2019 C&P Examination.

However, in August 2020, the Board found the May 2019 VA examination and August 2019 VA addendum opinion inadequate to decide the claim. In this regard, the Board found that no examiner had provided an explicit and adequate opinion as to whether the Veteran's erectile dysfunction is proximately due to, the result of, or aggravated by his migraine disability.

Furthermore, as per the August 2020 Board remand directives, in August 2020, the AOJ obtained an addendum opinion. The examiner opined that it is less likely than not that the Veteran's erectile dysfunction has been caused or aggravated by his service-connected migraines, or medications prescribed to treat migraines. As rationale, the examiner stated that, based on his medical knowledge, migraine and/or migraine medications used to treat migraines do not cause erectile dysfunction. Moreover, the examiner stated that if medications for erectile dysfunction, such as Sildenafil were discontinued secondary to headaches, that does not mean it caused the erectile dysfunction, and other modalities of treatment for erectile dysfunction could be used if Sildenafil could not be used. See 8/31/2020 C&P Examination. However, as discussed above, in the February 2022 JMPR, the parties agreed that the August 2020 opinion was inadequate to decide the claim. In this regard, the VA examiner concluded that, generally, medications used to treat migraines do not cause erectile dysfunction; however, the examiner did not identify which medication or medications the Veteran took for his erectile dysfunction or his migraines.

Moreover, as per the June 2022 Board remand directives, in October 2022, the AOJ obtained an addendum opinion. The reviewing examiner opined that it is less likely than not that erectile dysfunction is proximately due to or the result of the Veteran's service-connected disabilities. As rationale, the examiner stated that "[t]he Veteran was diagnosed with migraine headaches more than fifteen years before the onset of his [erectile
 the August 2020 opinion was inadequate to decide the claim. In this regard, the VA examiner concluded that, generally, medications used to treat migraines do not cause erectile dysfunction; however, the examiner did not identify which medication or medications the Veteran took for his erectile dysfunction or his migraines.

Moreover, as per the June 2022 Board remand directives, in October 2022, the AOJ obtained an addendum opinion. The reviewing examiner opined that it is less likely than not that erectile dysfunction is proximately due to or the result of the Veteran's service-connected disabilities. As rationale, the examiner stated that "[t]he Veteran was diagnosed with migraine headaches more than fifteen years before the onset of his [erectile dysfunction] and he was [diagnosed] with erectile dysfunction prior to being prescribed Flexeril and he continues to experience erectile dysfunction when Valium is not being prescribed. The [V]eteran states that he is on Flexeril and Valium for his headaches[;] however[,] the medical records do not reveal that he is currently prescribed Valium. He was diagnosed with erectile dysfunction in 2005 and he was not on Flexeril at that time." The reviewing examiner also provided a negative aggravation opinion. As rationale, the examiner stated that there is no evidence to support aggravation since "[t]here are no complaints by the [V]eteran and there are no objective findings to suggest that the [V]eteran['s] erectile dysfunction has worsened. The progress note dated December 27, 2021[,] reports that the erectile dysfunction is stable on Cialis [as needed]." See 10/7/2022 C&P Examination. However, in November 2022, the Board found the October 2022 VA addendum opinion inadequate to decide the claim. In this regard, the Board noted that VA records indicated that the Veteran had an active prescription for Diazepam, which is the generic name for Valium, as recently as February 2021. See 10/11/2022 CAPRI, at page 173. Further, the examiner's rationale did not discuss a possible interaction between the Veteran's erectile dysfunction and Diazepam or Valium.

As per the November 2022 Board remand directives, in January 2023, the AOJ obtained an addendum opinion. The reviewing examiner opined that the Veteran's erectile dysfunction is less likely than not proximately due to, the result of, or aggravated by any of the Veteran's service-connected disabilities or medication.  As rationale, the examiner noted that the Veteran had erectile dysfunction after service and before his depression. See 1/27/2023 C&P Examination. However, in June 2023, the Board found the January 2023 VA addendum opinion inadequate to decide the claim. The examiner did not provide an adequate rationale for why the Veteran's erectile dysfunction is not caused by his service-connected disabilities. In this regard, the Board noted an opinion was issued by the United States Court of Appeals for Veterans Claims (Court), which held that "for a veteran to be service connected on a secondary basis under a causation theory, the primary disability need not be service connected, or even diagnosed, at the time the secondary condition is incurred." Frost v. Shulkin, 29 Vet. App. 131 (2017).

As per the June 2023 Board remand directives, in July 2023, the AOJ obtained an addendum opinion. The Board finds the July 2023 VA addendum opinion to be highly persuasive and worthy of much weight regarding the issue of whether the Veteran's current erectile dysfunction is due to his service-connected disabilities for the reasons explained below. The reviewing examiner opined that it is less likely than not that the erectile dysfunction is proximately due to or the result of the Veteran's service-connected migraines. As rationale, the examiner stated that "[a]lthough there is an association between migraine headaches and [erectile dysfunction], a causative relationship has not been established or found upon literature review." Additionally, the examiner opined that erectile dysfunction is less likely than not aggravated by the Veteran's service-connected migraines. As rationale, the examiner stated that there was no supporting subjective complaints or objective findings to suggest that the Veteran's erectile dysfunction was aggravated from having to stop taking the erectile dysfunction medication, Sildenafil. See 7/30/2023 C&P Examination.

The examiner further opined that the erectile dysfunction is less likely than not proximately due to or the result of the Veteran's service-connected acquired psychiatric disorder. As rationale, the examiner stated that the record showed onset of depression in 2010 when he was diagnosed with a knee disability and sought help for his depression in September 2012 with Mirtazapine. Additionally, the examiner stated that not only did the Veteran's onset and diagnosis of erectile dysfunction
 Veteran's service-connected migraines. As rationale, the examiner stated that there was no supporting subjective complaints or objective findings to suggest that the Veteran's erectile dysfunction was aggravated from having to stop taking the erectile dysfunction medication, Sildenafil. See 7/30/2023 C&P Examination.

The examiner further opined that the erectile dysfunction is less likely than not proximately due to or the result of the Veteran's service-connected acquired psychiatric disorder. As rationale, the examiner stated that the record showed onset of depression in 2010 when he was diagnosed with a knee disability and sought help for his depression in September 2012 with Mirtazapine. Additionally, the examiner stated that not only did the Veteran's onset and diagnosis of erectile dysfunction precede the Veteran's onset of symptoms and diagnosis of depressive disorder, but medical research reveals the etiology of erectile dysfunction is multifactorial and although there is a high comorbidity between erectile dysfunction and depression, a causal relationship is not proven. Further, the examiner opined that erectile dysfunction is less likely than not aggravated by the Veteran's service-connected psychiatric disorder. As rationale, the examiner stated that there is lack of sufficient subject complains and objective measures upon review of the file to determine that the Veteran's erectile dysfunction was aggravated by his service-connected acquired psychiatric disorder. Id.

Based on this, the Board finds that the rationale from the July 2023 VA addendum opinion is logically supported, based on familiarity with the Veteran's relevant medical history and deserves great weight. Additionally, the Board places great probative weight on the July 2023 VA addendum opinion in this case, as it is consistent with the evidence of record and based upon medical knowledge and skill, as well as a review and analysis of the Veteran's specific disability picture, to include consideration of relevant facts such as the post-service medical record. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (stating that a medical report must be read as a whole in the context of the claim and, even an opinion lacking in detail may be provided some probative value based upon the amount of information and analysis contained therein).

Moreover, none of the available treatment records suggests a relationship between the Veteran's erectile dysfunction and his service-connected migraines and depression, and the only pertinent VA medical opinions of record, who had a thorough review of all pertinent evidence, found it less likely than not that the Veteran's erectile dysfunction was due or aggravated by the service-connected migraines or depression, to include the medications used to treat the disabilities. Thus, the only probative opinions regarding secondary service connection weigh against the claim, and the Veteran has not presented or identified any medical opinion or other competent evidence that, in fact, supports his claim.

The Board also acknowledges the lay statements from the Veteran. Such statements assert that the Veteran's erectile dysfunction is due to his service-connected depressive disorder and migraine disability, to include the medication used to treat the disabilities. See 4/10/2015 VA 21-526b; see also 11/25/2015 VA 21-526b. However, the Veteran is not competent to attribute his symptoms to his service-connected disabilities as the record does not reflect that he has medical training and/or experience. Jandreau, 492 F.3d 1377. Therefore, the Veteran's opinion on the etiology of the current erectile dysfunction is not competent and it lacks weight. The competent medical evidence, such as the July 2023 medical opinion, heavily outweighs the Veteran's opinion and tends to show that the Veteran's erectile dysfunction is not due to or aggravated by his service-connected disabilities. As discussed above, the Board finds the July 2023 opinion to be probative and deserving weight as there is a supporting rationale why, to include reference to relevant facts in the record.

In addition, the Board has considered the medical articles submitted by the Veteran purporting to demonstrate a relationship between the medications used to treat his service-connected disabilities and the claimed erectile dysfunction. The Court has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discussed generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998). In this case, however, the medical text evidence is not accompanied by an opinion of a medical professional. Also, to the extent that the article suggests a possible relationship between the medications and erectile dysfunction, it fails to establish with any degree of certainty a relationship between the medications the Veteran takes for his service
 if the medical article or treatise evidence discussed generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998). In this case, however, the medical text evidence is not accompanied by an opinion of a medical professional. Also, to the extent that the article suggests a possible relationship between the medications and erectile dysfunction, it fails to establish with any degree of certainty a relationship between the medications the Veteran takes for his service-connected disorders and his development of erectile dysfunction.

In sum, as the evidence weighs against the claim (that is to say, is neither in approximate balance nor nearly equal), the benefit-of-the-doubt rule is inapplicable, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310(a).

 

 

L.M. YASUI

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J.F., 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.