ERECTILE DYSFUNCTION

WENDY DAKNIS · 2024 · Case ID: 24024692

DENIED

Summary

The Veteran, an Army and Navy veteran who served from June 1985 to May 1991, appeals the denial of service connection for erectile dysfunction (ED). The Veteran contends that his ED is secondary to his service-connected PTSD, lumbar strain with radiculopathy, neurogenic bladder, and medications prescribed for these conditions. The Board reviewed the evidence, including multiple VA examinations and a private medical opinion. The March 2024 VA examination found no chronicity of ED during service and opined that a post-service event was a more likely etiology, concluding ED was less likely than not incurred in or caused by service. Previous VA examinations were found inadequate for failing to address the Veteran's PTSD or providing speculative opinions regarding medication effects. A private physician's opinion suggesting medication could cause ED was deemed too speculative. The March 2024 VA examiner also addressed the Veteran's PTSD, opining that ED was less likely than not a result of or aggravated by PTSD, stating the connection was independent of penile erection dysfunction. The Board found the March 2024 VA opinions adequate and probative, concluding that a nexus for ED secondary to other conditions or medications was not established. The Board denied service connection for ED, noting the evidence persuasively weighed against the claim and rendered the benefit of the doubt doctrine inapplicable.

Rationale

No chronicity of ED during service found.; Post-service event more likely etiology for ED.; Previous VA exams deemed inadequate; March 2024 VA exam found ED less likely than not related to service.; Private physician opinion deemed too speculative.; No nexus established for ED secondary to PTSD, lumbar strain, neurogenic bladder, or medications.

Service Branch

ARMY/NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

20-26 135

Full Decision Text

Citation Nr: 24024692
Decision Date: 06/27/24 Archive Date: 06/27/24

DOCKET NO. 20-26 135
DATE: June 27, 2024

ORDER

Entitlement to service connection for erectile dysfunction (ED) is denied.

FINDINGS OF FACT

1. The Veteran's ED was not incurred in or caused by active service, nor may it be presumed to have been incurred therein.

2. The evidence does not show that the Veteran's ED was caused or aggravated by a service-connected disability, including the medications used to treat any service-connected disability.

CONCLUSION OF LAW

The criteria for service connection for ED have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSION

The Veteran served on active duty in the United States Army from June 1985 until October 1985 and in the United States Navy from August 1986 to May 1991.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran perfected his appeal to the Board in a June 2020 Form 9 and requested a hearing. However, the Veteran withdrew the hearing request in a July 2022 letter prior to his scheduled August 2022 Board hearing. See 38 C.F.R. § 20.704(e). The Board remanded the claim in January 2024 for further development; the matter now returns to the Board for appellate review.

Entitlement to service connection for ED.

The Veteran contends that he should be service connected for his ED secondary to his other service-connected disabilities. Specifically, he claims that his ED is secondary to his service-connected posttraumatic stress disorder (PTSD) and/or chronic lumbar strain with bilateral lower extremity radiculopathy and neurogenic bladder. See November 2006 and October 2018 VA examination reports. This includes the contention that his ED is related to the medication prescribed for his service-connected conditions. See October 2022 representative letter.

Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Service connection may also be granted on a secondary basis. Secondary service connection will be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).

The Board is responsible for determining whether the evidence persuasively supports the claim or is in approximate balance, with the Veteran prevailing in either event, or whether the evidence is persuasively against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. 38 U.S.C. § 5107; see Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

Turning to the evidence for direct service connection, the Veteran was diagnosed with ED in approximately 2002 or 2003. See March 2024 VA examination. The service treatment records do not contain complaints, treatment, or diagnosis for ED. The March 2024 VA examination gave an adequate opinion on direct service connection. The examiner opined that the record showed no chronicity of ED during service or after service, and a post-service event, illness, or injury was a more likely etiology. The examiner's opinion was that the Veteran's ED was less likely than not incurred in or caused by an in-service injury, event, or illness. The Board finds this exam to be probative, as the record does not support a finding of a nexus between an in-service event and the Veteran's current diagnosis. Therefore, the three elements of direct service connection are not met, and entitlement to direct service connection for ED is not warranted.

Turning to the evidence for secondary service connection, in October 2018, the Veteran was afforded an examination to assess the nature and etiology of his ED. There, the October 2018 examiner opined that the Veteran's ED "less likely than not...has secondary service connection." As rationale, the examiner described the physiology of ED, which "could be the result of trauma, disease of [the] penis, [or] injury to penis or spinal cord." See October 2018 examination report. However, the examiner noted "there has been no reported injury to [the Veteran's] spinal cord that results in bowel, bladder, or ED," and all urologist progress notes "are silent for the cause of ED as it relates to lumbar strain." In November 2018, the same examiner provided an addendum opinion stating that medical literature reflects that a neurogenic bladder causes urinary leakage and urinary tract infections, not ED; therefore, ED is not a complication of a neurogenic bladder. These opinions did not address whether the Veteran's ED was aggravated by his service-connected lumbar spine condition and provided no opinion regarding the Veteran's PTSD. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). As such, the medical opinion and addendum are inadequate and hold no probative value.

In April 2020, a private physician, Dr. J.D., was asked whether the Veteran's ED was secondary to his back, bladder, or PTSD medication. Dr. J.D. noted the Veteran's prescribed medication list and stated that "duloxetine, the fluoxetine, and oxybutynin...as likely as not, could be causing ED." See April 2020 Dr. J.D. medical opinion. Although Dr. J.D. noted that he reviewed all submitted medical materials including the Veteran's current drug list, and that he researched the listed medication, the statement that the Veteran's ED "could be" caused by his medication is too speculative a medical opinion and is inadequate to establish a medical nexus. See Polovick v. Shinseki, 23 Vet. App. 48, 54 (2009). Here, Dr. J.D. provided an opinion based on a standard of proof much lower than necessary to establish service connection. Therefore, the Board finds this examination to be inadequate and of no probative value.

In a March 2024 VA opinion, the examiner addressed Dr. J.D.'s assertion that the Veteran's medication likely as not could be causing ED and stated that "declaring the primary cause of Veteran's ED... is mere speculation." The examiner explained that the most common cause of ED is insufficient blood flow to the penis and that the "Veteran's conditions that would most likely chronically contribute to this are his DM2, hypertension, and hyperlipidemia." However, the examiner stated that "choosing one or a combination of potential primary causes, aggravating factors, and/or risk factors among a multitude of possibilities is mere speculation." The examiner explained that this also applies to aggravation in the same way, and it is essentially impossible to know exactly what is causing the Veteran's ED.

The March 2024 examiner gave opinions on each of the Veteran's conditions. The examiner opined that the Veteran's ED was less likely than not a result of, or aggravated by, (1) his PTSD and/or chronic lumbar strain with disc bulge, bilateral lower extremity radiculopathy, and neurogenic bladder, to include the prescribed medication; (2) his hearing loss or medications; (3) his postoperative capsulorrhaphy of the left shoulder with a history of dislocations or medications; (4) his linear scar after shoulder surgery and/or its medications; (5) his tinnitus; (6) his left lower extremity radiculopathy-sciatic or neuropathy/radiculopathy medications; (7) his thoracic spine scoliosis or medications; (8) his chronic lumbar strain with L4-5 disc bulge or medications; (9) linear scar status post shoulder surgery; and (10) his right lower extremity radiculopathy, sciatic nerve, or medications. The examiner opined that the etiology of the Veteran's ED was unable to be determined without speculation, and although there is medical literature associating/correlating ED with a multitude of conditions and medications, association and correlation are not the same as etiological causation, and aggravation operates under the same principle.

The March 2024 examiner concurred with the October 2018 examiner that a neurogenic bladder condition is not considered a potential cause and/or risk factor for ED, as there is no medical basis on which to suspect neurogenic bladder as a possible cause of Veteran's ED. Although the neurogenic bladder medication, oxybutynin, has an associated risk of ED, an associated risk is not the same as etiological causation.

The March 2024 examiner also thoroughly explained a missing piece of the previous October 2018 VA examination, a discussion of the Veteran's post-traumatic stress disorder (PTSD) as it relates to ED. The examiner opined that the Veteran's ED is less likely than not a result of, or aggravated by, his PTSD with alcohol use disorder. The examiner explained that "during heightened stress and/or anxiety, the sympathetic nervous system is activated resulting in difficulty with parasympathetic processes such as sexual arousal/achieving an erection. Depending on the severity of the psychogenic condition, there may be more or less time spent in either a sympathetic state or parasympathetic state, however this is independent of/unrelated to a dysfunction of the penile erection process."

The March 2024 VA opinions are adequate, as they were thoroughly explained and cited relevant facts in the record such as the relevant prescription medications at issue in Dr. J.D.'s medical opinion. The record shows that the examiner completed a thorough review of the file, and adequately described how the etiology of the Veteran's ED was relatively impossible to determine, without speculation, and whether the Veteran's ED was less likely than not a result of, or aggravated by, any of the Veteran's current ailments or medications. See Nieves-Rodriguez, 22 Vet. App. at 304; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Therefore, the Board finds that the March 2024 VA opinions are the most probative medical evidence of record. Because the examiner's opinions show that a nexus for ED secondary to the Veteran's other service-connected conditions and medications had not been established, entitlement to secondary service connection for ED is not warranted.

In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the evidence of record persuasively weighs against the Veteran's claim for service connection for ED, such doctrine is not applicable in the instant appeal, and entitlement to service connection is not warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

The Board is sympathetic to the Veteran and understands that the Veteran's ED has significant effects on the Veteran's daily life. However, the record unfortunately does not support service connection for ED.

Wendy Daknis

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Clark, C.

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.
in the instant appeal, and entitlement to service connection is not warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

Wendy Daknis

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Clark, C.

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