SLEEP APNEA SYNDROMES (OBSTRUCTIVE CENTRAL MIXED)

BETHANY L. BUCK · 2024 · Case ID: 24033724

GRANTED

Summary

The veteran, who served in the U.S. Navy from June 1989 to June 1995 and January 2002 to December 2002, with additional Reserve service, appeals the denial of service connection for obstructive sleep apnea (OSA) and erectile dysfunction (ED). The veteran claimed OSA was directly related to service or a Persian Gulf presumptive illness, and later asserted it was secondary to service-connected hypertension. For ED, the veteran claimed secondary service connection due to service-connected migraines, hypertension, depression, and their medications. The Board found the evidence sufficient to grant both claims, resolving reasonable doubt in the veteran's favor. For OSA, the Board noted conflicting evidence regarding onset and diagnosis but found the veteran's and his wife's competent testimony, supported by their medical training, more probative. The Board found the VA examiners' opinions regarding OSA had low probative value due to incomplete consideration of evidence and factual inaccuracies. For ED, the Board found VA examiner opinions regarding migraines and topiramate to have low probative value due to factual inaccuracies about medication dosage and failure to consider relevant medical articles. While acknowledging hypogonadism and obesity as contributing factors, the Board found medical reasoning supported a nexus between ED and migraine medication, hypertension, and mental health disorder, granting the claim on a secondary basis. Service connection for OSA and ED were granted.

Rationale

Competent and credible evidence of onset during active duty and continuity of symptoms.; Conflicting VA opinions, with Board finding prior opinions had low probative value.; Reasonable doubt resolved in veteran's favor due to equipoise.

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

16-36 662

Full Decision Text

Citation Nr: 24033724
Decision Date: 12/03/24 Archive Date: 12/03/24

DOCKET NO. 16-36 662
DATE: December 3, 2024

ORDER

Service connection for obstructive sleep apnea is granted.

Service connection for erectile dysfunction is granted.

FINDINGS OF FACT

1. The evidence is in equipoise as to whether the Veteran's obstructive sleep apnea that was diagnosed years after service is related ot his active duty.

2. The Veteran's erectile dysfunction was caused by service-connected disabilities.

CONCLUSIONS OF LAW

1. The criteria for service connection for obstructive sleep apnea are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for erectile dysfunction are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had honorable active duty service in the U.S. Navy from June 1989 to June 1995 and January 2002 to December 2002, with additional Reserve service.

This matter initially came before the Board of Veterans' Appeals (Board) on appeal from rating decisions in September 2016 and July 2017, which were merged for Board review. The Veteran testified in June 2019 at a Board hearing, and the Board remanded the matter in October 2019 and denied the claims in an October 2021 decision. The Veteran appealed to the Court of Appeals for Veterans Claims (Court), which vacated and remanded that decision in part, including the issues now on appeal, in August 2022 pursuant to a Joint Motion for Partial Remand.

The Board then remanded the matter in December 2022 for additional records and examinations, and a supplemental statement of the case (SSOC) was issued in April 2024. The Veteran testified at a Board hearing before the undersigned VLJ in October 2024. During the hearing, the Veteran (through his representative) waived initial review by the agency of original jurisdiction (AOJ) of documentary evidence being submitted and any evidence added to the claims file after the SSOC. The evidence of record is now sufficient to fully grant both claims.

Service Connection

Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38?U.S.C. §§?1110, 1131; 38?C.F.R. §?3.303. Generally, the three-element test for service connection requires: (1)?a current disability; (2)?in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

Secondary service connection will be granted if the evidence demonstrates that a current disability is proximately due to or the result of, or is aggravated beyond its natural progression, by service-connected disability. 38 C.F.R. § 3.310. Secondary service connection is warranted for any incremental increase in disability, meaning any additional impairment of earning capacity, in a non-service-connected disability resulting from a service-connected condition, regardless of its permanence. Ward v. Wilkie, 31 Vet. App. 233 (2019).

In adjudicating the merits of such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant. 38?U.S.C. §?5107(b); 38?C.F.R. §?3.102.

1. Service connection for obstructive sleep apnea

The Veteran submitted his claim for obstructive sleep apnea (OSA) in November 2015. He primarily contends that this condition had an onset during active duty. See, e.g., June 2019 and October 2024 hearings, August 2022 appellate brief. He has also asserted that this condition should be considered under the presumptive provisions for certain Persian Gulf veterans (38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317), as sleep disturbances may be a sign or symptom of an undiagnosed illness. See May 2016 Veteran statement, August 2017 substantive appeal (VA Form 9), June 2019 hearing. The Veteran further asserted during his October 2024 hearing that his OSA is secondary to his service-connected hypertension.

As
He primarily contends that this condition had an onset during active duty. See, e.g., June 2019 and October 2024 hearings, August 2022 appellate brief. He has also asserted that this condition should be considered under the presumptive provisions for certain Persian Gulf veterans (38 U.S.C. §§ 1117, 1118; 38 C.F.R. § 3.317), as sleep disturbances may be a sign or symptom of an undiagnosed illness. See May 2016 Veteran statement, August 2017 substantive appeal (VA Form 9), June 2019 hearing. The Veteran further asserted during his October 2024 hearing that his OSA is secondary to his service-connected hypertension.

As explained below, the evidence of record is now sufficient to grant service connection on a direct basis, when resolving reasonable doubt in the Veteran's favor. Although the Veteran had eligible service under section 3.317 in Kuwait and Saudi Arabia in 1991 and 2002, such provisions need not be further discussed because a grant is warranted under section 3.303. As this results in a full grant of the benefit sought on appeal, secondary service connection need not be addressed.

The Veteran has a current disability diagnosis of OSA through an August 2014 private sleep study, with subsequent treatment by a CPAP machine noted in VA treatment records through 2024, as well as in several VA examinations.

There is also competent and credible evidence of an onset of symptoms during active duty that continued to the present, and a nexus to service from individuals with medical training or expertise, to include the Veteran and his spouse. Although there is conflicting evidence as both of these elements, reasonable doubt is resolved in the Veteran's favor to find that these two elements are satisfied.

The Veteran's service personnel records reflect that he has medical training as a corpsman during service, and he further reported in his August 2017 VA Form 9 that he has additional training as an EMT and worked as a corrections medical specialist. The Veteran's wife also indicated in May 2024 that she has medical training as a registered nurse since they were married in 1992. Thus, their reports as to a diagnosis for his in-service symptoms and a nexus to service have more probative value than general lay statements due to their history of medical training.

Concerning the nature and timing of his symptoms and diagnosis, the Veteran and his wife have given competent and generally consistent reports of him having ongoing symptoms since service of loud snoring, waking up gasping for air and coughing, and not breathing at times while sleeping (apneas or apneic episodes). They identified these symptoms as beginning between 1990 and 1993. The Veteran's wife recalled that, since they married in 1992, there were many times when she had to wake him up during the night due to not breathing or heavy snoring, and she needed him to change positions so that she could sleep. They both recalled him seeking treatment for such symptoms during service, and that he was told that he had bronchitis and was given an albuterol inhaler. After service, the Veteran was diagnosed with OSA by a sleep study in August 2014, and a prescribed CPAP machine improved his snoring. The Veteran became obese after service, but he and his wife reported that he had the same symptoms of OSA during service and through the present after losing more than 100 pounds, and he still requires a CPAP for treatment. See, e.g. June 2019 and October 2024 Board hearings; May 2024 statement from Veteran's wife; April 2021 appellate brief from representative; see also December 2015 and June 2016 VA examinations.

Service treatment records confirm that the Veteran was treated for symptoms diagnosed as bronchitis or a viral infection on several occasions. A February 1991 record noted complaints of coughing and wheezing for four days, and that he had a history of treatment for bronchitis with an inhaler. The Veteran reported that the cough bothered him most at night. In an October 1993 surveillance form for respiratory protection, the Veteran reported being treated for bronchitis in the past, with the most recent episode about a year earlier. A July 1999 record (while in Reserve status) noted a nonproductive cough that was worst at night for six days, and his throat had moderate redness; the assessment was a viral syndrome.

Reports of Medical History during active duty in March/April 1995 and February 2002 reflect that the Veteran reported ear, nose, or throat (ENT) trouble, but he denied shortness of breath, bronchitis, wheezing, cough at night, or frequent trouble sleeping. Reports of Medical Examination at those times found him clinically normal. While he was in Reserve status between active
form for respiratory protection, the Veteran reported being treated for bronchitis in the past, with the most recent episode about a year earlier. A July 1999 record (while in Reserve status) noted a nonproductive cough that was worst at night for six days, and his throat had moderate redness; the assessment was a viral syndrome.

Reports of Medical History during active duty in March/April 1995 and February 2002 reflect that the Veteran reported ear, nose, or throat (ENT) trouble, but he denied shortness of breath, bronchitis, wheezing, cough at night, or frequent trouble sleeping. Reports of Medical Examination at those times found him clinically normal. While he was in Reserve status between active duty periods, an October 2000 record noted shortness of breath and difficulty breathing while running. He had surgery in November 2000 to remove polyps, drain sinuses, and straighten a deviated septum due to injury two years earlier. A November 2002 Report of Medical Assessment noted shortness of breath. These records do not necessarily rule out symptoms of OSA during service, as the Veteran may not have considered his OSA symptoms as "trouble sleeping" or shortness of breath.

The Veteran and his wife both reported that the diagnosis of bronchitis or exercised-induced bronchospasm during service did not make sense to them at the time, as his symptoms occurred while he was sleeping, not while exercising. They believe he was misdiagnosed, as OSA was not well known or understood when he first had symptoms in the 1990's. They both indicated that it should be obvious based on current medical knowledge that he had OSA in service. The Veteran's wife further stated that she found no correlation between his OSA and his period of obesity, reasoning that he had similar symptoms during service prior to his weight gain and he still required a CPAP for OSA more recently after significant weight loss. See, e.g. June 2019 and October 2024 hearings; May 2024 statement from wife; see also April 2018 statement from representative (labeled VA Form 646).

The Veteran first sought VA treatment in January 2014, after reporting for a Persian Gulf examination in August 2013. Neither of these records mentioned sleep problems or possible OSA symptoms or diagnosis. However, the provider noted that he was previously seen at Ochsner, which the Veteran also reported for a VA claim in 2013. No treatment records from Ochsner or from the non-military ENT provider in 2000, as referenced in service treatment records, were requested or obtained. Such records may have contained information relevant to OSA.

During a May 2014 VA general medical examination for other conditions, the Veteran reported that he snored and had apneic spells for about ten years (or around 2014), but he had never had a sleep study. He also reported being diagnosed with exercise-induced bronchospasm about two years earlier and that prescribed albuterol helped. No nexus opinion was provided as to OSA. At other times, as summarized above, the Veteran and his wife consistently reported an onset of symptoms between 1990 and 1993, with his wife observing them since 1992.

In July 2014, a VA pulmonology record noted that an OSA screening questionnaire showed a moderate to high risk of OSA, and a primary care record noted possible sleep apnea and referred the Veteran for a sleep study. The August 2014 private sleep study report that diagnosed mild OSA reflects objectively observed snoring and hypopneas (shallow breathing or a low respiratory rate while sleeping). The study noted the Veteran's weight as 290 pounds and a body mass index (BMI) of 40, and advised that alcohol, sedatives, and weight gain may worsen his OSA.

The Veteran's November 2015 claim was for OSA and exercise-induced bronchospasm. A December 2015 VA examiner for respiratory conditions opined that exercise-induced bronchospasm was less likely than not related to symptoms or treatment for "bronchitis" in service. No examination or opinion was given for OSA. However, the examiner's reasoning was that the Veteran had a history of OSA and his reported history of waking up from sleep and gasping for breath, to include during service, was more suggestive of OSA than bronchitis or exercise-induced bronchospasm. The examiner noted the Veteran's reports of being diagnosed with bronchitis and treated with an albuterol inhaler in service, and that an October 1993 service record noted his reported bronchitis. The examiner also noted the Veteran's report of being diagnosed with exercise-induced bronchospasm and treated with an albuterol inhaler about two years prior to the
for "bronchitis" in service. No examination or opinion was given for OSA. However, the examiner's reasoning was that the Veteran had a history of OSA and his reported history of waking up from sleep and gasping for breath, to include during service, was more suggestive of OSA than bronchitis or exercise-induced bronchospasm. The examiner noted the Veteran's reports of being diagnosed with bronchitis and treated with an albuterol inhaler in service, and that an October 1993 service record noted his reported bronchitis. The examiner also noted the Veteran's report of being diagnosed with exercise-induced bronchospasm and treated with an albuterol inhaler about two years prior to the examination.

After the Veteran requested reconsideration based on the Persian Gulf presumptions, a June 2016 VA examination for sleep apnea noted the Veteran's report of snoring and having apneic spells (or episodes of not breathing) since about 1992, and that a sleep study in 2014 resulted in a diagnosis of OSA and treatment with a CPAP machine, which improved his snoring. This examiner opined that the Veteran's OSA was less likely than not due to toxic exposures including burn pits during Persian Gulf service in Southwest Asia, and explained that OSA is due to an anatomic narrowing or collapse of the airway during sleep. This examiner did not address a nexus based on continuity since active duty.

After a Board remand, a December 2019 VA examination (labeled as received February 2020) and September 2020 addendum also opined that the Veteran's OSA was not due to Persian Gulf exposures. The examiner reasoned that OSA occurs when the throat muscles relax, and the Veteran's condition was due to morbid obesity. The examiner further opined that the Veteran's OSA was less likely than not present during service or related to service. The examiner reasoned that there were no complaints of symptoms consistent with OSA during service; and the complaints of coughing, wheezing, shortness of breath, and waking up gasping for breath were diagnosed as bronchitis in service and, thus, were related to bronchitis. The examiner stated that symptoms of OSA are when breathing repeatedly stops and starts when the throat muscles relax, and the condition is diagnosed with a sleep study. Coughing, "sneezing," and shortness of breath are unrelated to OSA; thus, such symptoms in service were not from OSA. This examiner did not address the Veteran's assertions that he was misdiagnosed in service and had OSA.

After another Board remand, a December 2023 VA examiner (labeled as received March 2024) gave a negative direct nexus opinion, stating that the Veteran's OSA was less likely than not related to exposures to burn pits and other toxins including fine particulate matter (BPOT) during his Persian Gulf service, as confirmed by an October 2023 VA memo concerning toxic exposure risk activities (TERA). The examiner explained that OSA is caused by repeated obstruction to the airway during sleep, as the airway intermittently narrows or collapses; and opined that the Veteran's OSA was more likely due to obesity. This examiner also opined that the 2015 examiner's comment that the symptoms during service were more likely due to OSA than bronchitis was merely speculation without a sleep study at that time.

A December 2023 VA general medical examination under Gulf War protocols (labeled as received March 2024) stated that the Veteran's OSA was multifactorial in nature with no clear etiology, but it was less likely than not related to TERAs or toxic exposure during his Persian Gulf service. The examiner reasoned that pharyngeal narrowing and closure during sleep is a complex phenomenon, and it is likely that multiple factors play a role in the pathogenesis. The examiner summarized potential contributing or risk factors, and noted that the most common causes of OSA in adults are obesity, male sex, and advanced age. However, the examiner did not apply the facts of this case to this general information.

Additionally, the 2023 examiner did not consider the competent lay reports of continuous symptoms of snoring, waking up gasping for air, and not breathing at times while sleeping (apneic episodes) since service, or the competent opinions from the Veteran and his spouse as to such symptoms likely being OSA.

For the reasons noted above, the VA examination opinions after 2015 have low probative value concerning whether the Veteran had OSA, as opposed to bronchitis, during service or whether his diagnosis of OSA by sleep study in 2014 was related to his symptoms during service. However, the 2015 examiner's reasoning that the described symptoms in service were more suggestive of OSA is probative, despite the lack of a sleep study in service. In contrast to the notation by the 2023 examiner that the reasoning was only speculative, symptoms during service may be used to support a later diagnosis with appropriate testing.

Furthermore, the examiners who opined that the Veteran's OSA was due to obesity did not address the timing of his symptoms of OSA in relation to his obesity, whereas the Veteran and his wife did address the timing and found no correlation.

Accordingly, the evidence is at least in relative equipoise as to whether the Veteran had OSA during service and since that time, with consideration of the testimony and opinions from the Veteran and his wife with medical training and knowledge. Thus, reasonable doubt is resolved in his favor, and the claim for OSA is granted.

2. Service connection for erectile dysfunction

The Veteran submitted his claim for erectile dysfunction (ED) in May 2017. He contends that his condition is secondary to service-connected disabilities, to include as a side effect of medications for treatment of such disabilities. See, e.g., February 2018 substantive appeal (VA Form 9), June 2019 and October 2024 hearings, April 2018 and August 2022 representative arguments. As explained below, the evidence of record is now sufficient to grant service connection based on secondary causation, when resolving reasonable doubt in the Veteran's favor.

A current disability diagnosis is established based on the Veteran's competent reports, as well as diagnoses in VA treatment records and examinations.

The Veteran primarily asserts that his ED was caused by medication to treat his service-connected migraines (topiramate/Topamax). During his June 2019 hearing, he testified that he did not have ED issues prior to going on this medication, and his doctor had never attributed his ED to a specific diagnosis.

During his October 2024 hearing, the Veteran further asserted that his ED is secondary to his now service-connected mental health disorder and hypertension, as well medications to treat those conditions. The Veteran clarified that he does not contend that his ED had an onset in service or is otherwise due to service, to include TERAs or BPOT during his Persian Gulf service, although such theories were developed by the AOJ. Rather, the Veteran contends that the December 2023 VA examination (labeled as received March 2024) with a negative opinion on that basis contains reasoning that supports a secondary nexus based on causation from hypertension and depression and medications to treat those conditions.

Concerning migraines and topiramate, a May 2017 VA examination gave a negative secondary opinion for ED. The examiner reasoned that although side effects of topiramate may include depression and anxiety, ED was not listed as an adverse or side effect of the drug. However, the Veteran subsequently submitted medical articles in August 2017 and May 2019, published in 2013 and 2014 respectively, indicating that studies had found topiramate causes ED and is possible at even lower doses, and the medication had been associated with orgasmic dysfunction in men. Such studies or similar medical research does not appear to have been considered for the 2017 VA examiner's opinion.

A December 2019 VA examination (labeled as received February 2020) noted an onset of ED in 2016, and that the Veteran took Viagra previously but had side effects, and he was now on Cialis with good effect. He also had a history of hypogonadism that was treated, in part, with testosterone injections. In giving a negative direct nexus opinion for exposures during Persian Gulf service, the examiner stated that hypogonadism is frequently a co-factor of ED in obese men, and it is related to excess body fat and high plasma levels of leptin. In particular, male obesity is frequently associated with low Total Testosterone (TT) levels.

In this regard, an August 2017 VA treatment record noted that the Veteran had hypogonadism and was being given weekly testosterone injections by an outside facility. The record appears to note such treatment since April 2016, but the non-VA records were not requested or obtained; they may contain relevant
history of hypogonadism that was treated, in part, with testosterone injections. In giving a negative direct nexus opinion for exposures during Persian Gulf service, the examiner stated that hypogonadism is frequently a co-factor of ED in obese men, and it is related to excess body fat and high plasma levels of leptin. In particular, male obesity is frequently associated with low Total Testosterone (TT) levels.

In this regard, an August 2017 VA treatment record noted that the Veteran had hypogonadism and was being given weekly testosterone injections by an outside facility. The record appears to note such treatment since April 2016, but the non-VA records were not requested or obtained; they may contain relevant information as to his ED. A December 2017 VA treatment record noted that the Veteran was self-injecting testosterone weekly for hypogonadism. As noted above, he reported an onset of ED in 2016, so possibly concurrent with treatment for hypogonadism.

Another December 2019 VA examination report (labeled as received February 2020) opined that the Veteran's ED was less likely than not caused or aggravated by his migraines or topiramate for that condition. The examiner stated that his ED was due to hypogonadism, reasoning that he had been on testosterone shots for that along with Cialis, and finding no correlation with migraines or its medications in this case. The examiner further stated that hypogonadism is not due to migraines; rather, male hypogonadism, also known as testosterone deficiency, is a failure of the testes to produce the male sex hormone testosterone, sperm, or both. It can be due to a testicular disorder or the result of a disease process involving the hypothalamus and pituitary gland. There is no anatomical, pathophysiological, hormonal, or neuronal correlation of causation or aggravation for ED or hypogonadism. However, this opinion does not reflect consideration of the medical articles submitted in August 2017 and May 2019, as noted in the opinion request.

In a September 2020 addendum, this VA examiner stated that the indicated evidence was reviewed and considered, and opined that the Veteran's ED was less likely than not caused by his migraines or its medication, based on the frequency of headaches and dose of medication. The examiner noted that Topamax (topiramate) was known to cause dose-dependent reversible ED when given for epilepsy. (This is similar to information noted in the articles submitted by the Veteran.) The examiner stated that this Veteran had about four headaches a month with full relief from Topamax at 50 mg per day, or one-half dose. Thus, he concluded that neither the headaches nor medication would play a role in the Veteran's ED due to the frequency and resolution after taking medication, as the headaches were not frequent and the medication was not consistent.

As noted by the Veteran's representative in August 2022 arguments, the examiner's rationale in 2020 was based on an inaccurate factual premise as to the dosage of Topamax. VA treatment records show that the Veteran was started on a trial of topiramate/Topamax in December 2015, and records through December 2017 indicate that he was to take 25 or 50 mg up to twice a day, for a total of 25, 50, 75, or 100 mg per day at various times. A March 2018 record noted that the dose had been increased to 25 mg in the morning and 75 mg in the evening, but it made the Veteran too sleepy, so the dose was decreased to the previous 25 mg in the morning and 50 mg in the evening. Subsequent records noted higher dosages of 150 mg total daily in November 2020, which was later decreased back to 25 mg in the morning and 50 mg in the evening, but was increased to 100 mg daily at bedtime in June 2021. Records from July 2021 through October 2024 reflect a prescription for 200 mg daily at bedtime and that the Veteran reported taking 100 mg at bedtime. Accordingly, the September 2020 VA opinions have very little probative value.

In a December 2023 VA opinion report (labeled as received March 2024), an examiner opined that the Veteran's ED was less likely than not caused by TERAs or BPOT during his Persian Gulf service, and also gave negative secondary nexus opinions. The examiner stated that the Veteran's ED had not progressed from the use of migraine medications or hypertension medications. Rather, the Veteran's hypogonadism and morbid obesity were the etiology of his ED. The examiner acknowledged that hypertensive medications have a side effect profile (or risk) of ED, but found no evidence of progression of ED
the Veteran reported taking 100 mg at bedtime. Accordingly, the September 2020 VA opinions have very little probative value.

In a December 2023 VA opinion report (labeled as received March 2024), an examiner opined that the Veteran's ED was less likely than not caused by TERAs or BPOT during his Persian Gulf service, and also gave negative secondary nexus opinions. The examiner stated that the Veteran's ED had not progressed from the use of migraine medications or hypertension medications. Rather, the Veteran's hypogonadism and morbid obesity were the etiology of his ED. The examiner acknowledged that hypertensive medications have a side effect profile (or risk) of ED, but found no evidence of progression of ED in treatment records. There was also no evidence of a link between migraine medications and exacerbation of ED, although the examiner noted that the side effect profile for topiramate was positive for ED. This opinion is conclusory or has incomplete rationale.

A few days later, a December 2023 report from a different examiner (labeled as received March 2024) for the male reproductive system again noted an onset of ED in 2016, and that the Veteran had a history of hypogonadism that was treated, in part, with testosterone injections. The examiner identified hypogonadism as the etiology for ED; however, no rationale was provided for this finding or opinion.

In a separate December 2023 opinion report, the same examiner gave a negative nexus opinion for Persian Gulf exposures, to include TERAs and BPOT. The examiner stated that the cause of ED is often multifactorial; and depression, performance anxiety, and other sexual disorders can be strong contributing factors even when organic causes also exist. Aging is an essential factor contributing to ED, including that cardiovascular diseases, hypertension, and other co-morbidities play an increasingly significant role in ED as the patient ages. The examiner listed multiple other causes of ED, including hypogonadism, sleep apnea, depression, and medications including antidepressants and antihypertensives. The examiner stated that there are strong correlations between ED, hypertension, depression, and a few other conditions, including that 40 and 30 percent of men with ED will have hypertension and vice versa, and men with depression are almost 40 percent more likely to have ED than men without depression. The report also states that prescription medications are thought to cause one-fourth (25 percent) of all cases of ED, including most antidepressants or selective serotonin reuptake inhibitors (SSRIs) and antihypertensive medications. The examiner further noted that up to 35 percent of men with ED will also have hypogonadism, and obesity is associated with a 50 percent increase in ED compared to men of normal weight.

The Veteran is competent to diagnose ED due to its observable nature, and he is also competent to give an opinion as to the underlying cause or etiology based on his medical training, as noted under the OSA analysis above. The date of onset of his ED is unclear from the evidence of record, as a July 2014 VA treatment record noted that he wanted a urology referral for ED and VA examinations indicated an onset in 2016. A January 2014 new patient record with VA primary care noted he was taking Fioricet for migraines and lisinopril for hypertension. As also noted in the analysis above, records from the Veteran's provider prior to January 2014 were not requested or obtained; they may contain relevant information in this regard.

For the reasons noted above, the VA examination opinions have low probative value as to secondary service connection for migraines and its medication, as they do not consider all relevant or factually accurate evidence. Although the evidence indicates that the Veteran's nonservice-connected hypogonadism and obesity contributed to the Veteran's ED, there is also medical reasoning to support a causal nexus between ED and his migraine medication, hypertension and his mental health disorder and their medications, to include in VA opinions for other theories.

Accordingly, the evidence is at least in relative equipoise as to whether the Veteran's ED was caused by his service-connected disabilities and medications, with consideration of relevant medical articles and the testimony and opinions from the Veteran with medical training and knowledge. Thus, reasonable doubt is resolved in his favor, and the claim for ED on a secondary basis is granted.

Bethany L. Buck

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board C. Wheatley

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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