ERECTILE DYSFUNCTION

Summary

The Veteran, an Army Veteran who served from November 2009 to April 2013, appeals the denial of service connection for erectile dysfunction as secondary to his service-connected lumbar spine degenerative disc disease (DDD). The Veteran claimed his erectile dysfunction was caused by chronic pain from his lumbar spine condition. The Board reviewed the evidence, noting that the Veteran's service treatment records were silent regarding erectile dysfunction complaints. While a private physician diagnosed erectile dysfunction, the Board found this opinion inadequate due to conclusory statements and lack of specific medical literature citations or a detailed rationale linking the condition to the Veteran's service-connected lumbar spine DDD. The Board also noted conflicting statements from the Veteran regarding the onset of erectile dysfunction, with an earlier VA consultation denying the condition. Two VA examinations concluded that the Veteran did not have a current diagnosis of chronic erectile dysfunction and found no medical nexus to service or to his service-connected lumbar spine DDD. The Board found the VA opinions more competent and probative than the private opinion. Although the Board applied the benefit of the doubt doctrine due to conflicting evidence regarding a current diagnosis, it found the evidence persuasively weighed against a service connection for erectile dysfunction. Therefore, service connection for erectile dysfunction as secondary to lumbar spine DDD was denied.

Rationale

No direct medical nexus to service; Conflicting medical opinions regarding diagnosis; Private opinion found inadequate due to conclusory nature and lack of citations; VA opinions found more competent and probative

Full Decision Text

Citation Nr: A25014674
Decision Date: 02/19/25	Archive Date: 02/19/25

DOCKET NO. 240209-415572
DATE: February 19, 2025

ORDER

Entitlement to service connection of erectile dysfunction as secondary to lumbar spine degenerative disc disease is denied.

FINDING OF FACT

The Veteran's erectile dysfunction is not secondary to service-connected lumbar spine degenerative disc disease disability and is not otherwise the result of an in-service injury or disease.

CONCLUSION OF LAW

The criteria for entitlement to service connection of erectile dysfunction have not been met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Army from November 2009 to April 2013.

Relevant Procedural History

The present appeal originates from an initial disability claim received on January 27, 2021, requesting an increased rating for lumbar spine degenerative disc disease and service connection of erectile dysfunction, gastroesophageal reflux disease (GERD), and right lower extremity nerve condition, all as secondary to lumbar degenerative disc disease (lumbar spine DDD).  See January 2021 VA Form 21-526EZ.  In a September 2021 Rating Decision, the Department of Veterans Affairs (VA) Regional Office (RO) denied the each of the claims for service connection upon finding no clinical diagnosis of erectile dysfunction, GERD, or right lower extremity nerve disabilities and no medical nexus between the Veteran's claimed disabilities and his service-connected lumbar spine DDD.

In October 2022, the Veteran filed a VA Form 20-0995 Decision Review Request: Supplemental Claim requesting reconsideration of the September 2021 Rating Decision.  In a May 2023 Rating Decision, the RO again denied service connection of erectile dysfunction upon finding the absence of both a clinical diagnosis of erectile dysfunction and a medical nexus between the Veteran's claimed erectile dysfunction and service-connected lumbar spine DDD.

In September 2023, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), in response to the May 2023 agency decision.  In January 2024, the RO issued the HLR decision on appeal, which considered the evidence of record at the time of the prior May 2023 decision.  Although the RO favorably found that new and relevant evidence had been received sufficient to warrant reconsideration of the Veteran's claim, the request for service connection was again denied for the reasons provided in the May 2023 Rating Decision.

In a February 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran appealed that denial to the Board of Veterans' Appeals (Board) and elected the Direct Review docket.  As an appeal in which the appellant requested, on the Notice of Disagreement, direct review by the Board without submission of additional evidence and without a Board hearing, the Board's decision is based on a review of the evidence of record at the time of the May 2023 agency decision on the issue on appeal.  38 C.F.R. § 20.301.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence.  38 C.F.R. § 3.2501.  If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered.  Id.  Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection

Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service.  38 U.S.C. § 1131; 38 C.F.R. § 3.303.  Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service.  See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service.  38 C.F.R. § 3.303(d).

Service connection may also be granted secondarily, for a
 C.F.R. § 3.303.  Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service.  See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service.  38 C.F.R. § 3.303(d).

Service connection may also be granted secondarily, for a disability that is proximately due to, or aggravated by, service-connected disease or injury.  38 C.F.R. § 3.310.  For secondary service connection to be granted, generally 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 determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value.  Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a).  When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.  38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (only when the evidence persuasively favors one side, or another is the benefit of the doubt doctrine not for application).

Erectile Dysfunction

The Veteran contends that his erectile dysfunction is secondary to his service-connected lumbar spine DDD disability.  Specifically, the Veteran alleges that his erectile dysfunction is the result of chronic and pervasive pain associated with his lumbar spine disability.  See January 2021 VA Form 21-4138.

The Board notes that the Veteran's erectile dysfunction claim was principally developed as one for secondary service connection based on his assertions in the January 2021 VA Form 21-526EZ claim form and his contemporaneous written statement.  The Veteran's service treatment records are silent for complaints, treatment, or diagnoses of erectile dysfunction, and there is no medical evidence or opinion of record which establishes a direct medical or causal relationship between the Veteran's erectile dysfunction and military service.  As the record does not substantiate entitlement to service connection of erectile dysfunction on a direct basis, there is no basis to warrant direct service connection, nor has the Veteran meaningfully asserted otherwise.

Thus, the question for the Board is whether the Veteran has a current disability that is proximately due to or the result of or is aggravated beyond its natural progression by his service-connected lumbar spine DDD disability.  As to whether the Veteran has a current disability of erectile dysfunction, the record contains conflicting medical evidence.  An April 2021 VA examiner concluded that the Veteran does not have and has never had any disability of the male reproductive system, citing a March 2019 statement from the Veteran denying erectile dysfunction and the lack of a prescription medication for treatment of erectile dysfunction.  See April 2021 VA Compensation and Pension (C&P) Examination.

Notwithstanding the examiner's findings, the record contains a private medical opinion by M.B., a Physician Assistant, reflecting a diagnosis of erectile dysfunction.  See November 2021 Private Medical Opinion.  In response thereto, the Veteran was scheduled for a VA examination on November 8, 2022, for which he failed to appear.  A December 2022 Report of General Information notes that the Veteran informed a VA representative that he was unable to attend exams and explicitly requested that his claims be rated based on information contained in the claims file.  See December 2022 VA Form 27-0820.  In March 2023, a VA examiner again concluded that the Veteran lacks a diagnosis of chronic erectile dysfunction.  The examiner further stated that the Veteran's private examination reflecting a diagnosis of acute erectile dysfunction is not evidence of a chronic diagnosis and a medical nexus was not established.  See March 2023 VA C&P Examination.

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.  38 U.S.C. § 5107. 
 to attend exams and explicitly requested that his claims be rated based on information contained in the claims file.  See December 2022 VA Form 27-0820.  In March 2023, a VA examiner again concluded that the Veteran lacks a diagnosis of chronic erectile dysfunction.  The examiner further stated that the Veteran's private examination reflecting a diagnosis of acute erectile dysfunction is not evidence of a chronic diagnosis and a medical nexus was not established.  See March 2023 VA C&P Examination.

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.  38 U.S.C. § 5107.  Thus, resolving doubt in favor of the Veteran, the Board finds that the Veteran has a current disability of erectile dysfunction and element one has been established.  Additionally, the Veteran is currently service connected for lumbar spine DDD, leaving the remaining issue of a medical nexus.

In an April 2021VA Medical Opinion, the Veteran reported that he gradually developed erectile dysfunction in 2018 and experiences difficulties in achieving an erection.  He stated that he does not take medication for the condition.  In a March 2019 VA Consultation, the Veteran denied experiencing erectile dysfunction.  See VA Treatment Records.  Upon review of his medical record, the VA examiner opined that the Veteran did not have an erectile dysfunction disability and thus, it is less likely than not proximately due to or the result of the Veteran's service-connected lumbar spine DDD disability.  As noted above, in a March 2023 VA medical opinion, the examiner again concluded that the Veteran lacked a current diagnosis, and therefore, a medical nexus was not established.

The Veteran was diagnosed with lumbar spine DDD in 2014, with a report of symptom onset as early as 2011, due to an in-service injury.  See May 2014 VA C&P (Thoracolumbar) Examination.  The earliest record containing a report of the Veteran's erectile dysfunction is January 2021, the date of claim, roughly 10 years after the onset of lumbar spine DDD symptoms.  This temporal gap in conjunction with the March 2019 denial of erectile difficulty countermands the Veteran's assertion that his erectile difficulties onset after being diagnosed with lumbar spine DDD.

In support of his claim, the Veteran provided lay statements and a private nexus opinion.  The Board has considered the lay statements of the Veteran.  To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and causation, and the Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent.  See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011).  In this case, the Veteran is only competent to report symptoms.  He is not competent to opine on the genesis of his erectile dysfunction, as that is a medically complex question which requires expertise that the Veteran has not demonstrated.  See Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007).

As to the private nexus opinion, the Veteran's provider broadly cited the etiology of his erectile dysfunction as "Lumbar Degenerative Disc Disease with Thoracic Strain."  The provider reported that medical literature supports that those suffering from chronic musculoskeletal pain experience a loss in sexual interest, arousal, or overall interference in intimacy with erectile and orgasm incapability related to mood changes, difficulty focusing, and hormonal changes related to chronic musculoskeletal pain.  However, no medical literature citations were included in the opinion.

Upon review, the Board finds the November 2021 medical opinion inadequate as it is conclusory, lacking in rationale and detail, and does not reflect review or consideration of the Veteran's medical history.  See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).  As noted above, the November 2021 medical opinion states that medical literature supports a causal relationship between the Veteran's lumbar spine DDD and erectile dysfunction, yet no such literature is cited; nor is there specific information included that directly relates to the Veteran to support the medical opinion.  While it may be apparent to the medical provider that there is a correlation between lumbar spine DDD and erectile dysfunction, the reasoning for such opinion must be provided for a fully informed decision to be rendered.  Thus, the Board finds the medical opinion inadequate for adjudicative purposes.  See Nieves-Rodriguez v
 history.  See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007).  As noted above, the November 2021 medical opinion states that medical literature supports a causal relationship between the Veteran's lumbar spine DDD and erectile dysfunction, yet no such literature is cited; nor is there specific information included that directly relates to the Veteran to support the medical opinion.  While it may be apparent to the medical provider that there is a correlation between lumbar spine DDD and erectile dysfunction, the reasoning for such opinion must be provided for a fully informed decision to be rendered.  Thus, the Board finds the medical opinion inadequate for adjudicative purposes.  See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), Barr v. Nicholson, 21 Vet. App. 303 (2007), Prejean v. West, 13 Vet. App. 444 (2000).

In sum, the Veteran's private opinion does not address the Veteran's medical history, physical manifestations, or provide a medical opinion upon which the Board can rely.  Therefore, the Board finds that the most competent and probative opinions of record addressing the question at issue in this case come from the VA medical opinions and both are against the claim.  The April 2021 VA opinion is based on an in-person examination and a review of the Veteran's complete medical history.  It provides a detailed explanation that contains clear conclusions and supporting rationale and is consistent with and supported by the evidence of record.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).  The March 2023 VA opinion, again considered the Veteran's complete medical history, including his private treatment records, and similarly concluded a medical nexus was absent.

While the Board finds that the Veteran has been diagnosed with erectile dysfunction, the record contains insufficient medical evidence to establish that his erectile dysfunction is proximately due to or aggravated beyond its natural progression by his service-connected lumbar spine DDD disability.  Thus, entitlement to service connection of erectile dysfunction secondary to lumbar spine DDD is not warranted.

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?

In reaching this conclusion, the Board has considered the benefit-of-the-doubt rule. However, the evidence is not in "approximate balance" or "nearly equal," and therefore the benefit-of-the-doubt rule does not apply.  Lynch, 21 F.4th at 776; see also Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001).  As the evidence persuasively weighs against the claim, the benefit-of-the-doubt rule does not change the outcome on this issue.  Accordingly, service connection for erectile dysfunction is not warranted and the claim is denied.  See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

 

 

RAY BARTO SLABBEKORN, JR.

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Regnart, Glenda M.

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.