CYSTITIS

Summary

The veteran, who served from June 1978 to June 1998, including service in Southwest Asia during the Persian Gulf War, appeals the denial of service connection for cystitis and seeks service connection for unspecified fatigue. The Board found that the evidence regarding cystitis was in equipoise, and resolving doubt in the veteran's favor, granted service connection. The Board noted conflicting medical opinions: a December 2015 VA exam found cystitis less likely than not related to service, while a January 2020 VA opinion found it at least as likely as not related to service, citing in-service abdominal pain. A July 2020 VA opinion found it less likely than not related due to lack of in-service diagnosis, but another July 2020 VA opinion found it at least as likely as not related to service, noting abdominal pain as a symptom of cystitis. The Board ultimately granted service connection for cystitis. The claim for unspecified fatigue was remanded for a new VA examination to determine the nature and etiology of the fatigue, including its relationship to environmental hazards in Southwest Asia, and to clarify the examiner's opinions regarding objective indications, diagnosis, and nexus.

Rationale

Evidence in equipoise; Benefit of doubt resolved in veteran's favor; Related to in-service abdominal pain

Full Decision Text

Citation Nr: 21017678
Decision Date: 03/25/21	Archive Date: 03/25/21

DOCKET NO. 18-07 096
DATE: March 25, 2021

ORDER

Entitlement to service connection for cystitis is granted.

REMANDED

Entitlement to service connection for unspecified fatigue is remanded.

FINDING OF FACT

Resolving reasonable doubt in the Veteran’s favor, his cystitis is at least as likely as not related to in-service abdominal pain.

CONCLUSION OF LAW

The criteria for service connection for cystitis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from June 1978 to June 1998, including service in Southwest Asia during the Persian Gulf War.

This matter comes before the Board of Veterans’ Appeals (Board) from a January 2016 rating decision from a Department of Veterans Affairs (VA) regional office (RO).

The Veteran appeared at a hearing before the undersigned Veterans Law Judge in May 2019.  A transcript of the hearing has been associated with the Veteran’s claims file.

These matters were last before the Board in September 2019, at which time the Veteran’s claim was remanded for further development. Unfortunately, there has not been substantial compliance with the Board’s previous remand regarding the issue of unspecified fatigue. Another remand is required for the issue of unspecified fatigue. Stegall v. West, 11 Vet. App. 268, 271 (1998).

1. Entitlement to service connection for cystitis

The Veteran asserts that cystitis is related to symptoms in service that have been the same to present day. 

The Board concludes that the Veteran has a current disability that is related to in-service abdominal pain. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a).

In a December 2015 VA examination, the examiner indicated the Veteran’s cystitis is less likely than not related to service because the Veteran’s symptoms at the examination were different than while on active duty. The examiner did not specify which symptoms were different and the Veteran testified that the symptoms have been the same. 

A May 2015 private medical opinion indicates cystitis as a current condition with abdominal pain. The opinion does not identify cystitis, just abdominal pain. 

The September 2019 Board decision found a new examination was warranted, based on review of the May and December 2015 opinions, to identify the symptoms the Veteran hs relating to cystitis and whether the condition is related to symptoms reported in service. 

In January 2020 VA medical opinion, the examiner opined the Veteran’s cystitis was at least as likely as not incurred in or caused by the claimed in-service event or illness. The examiner noted the condition was during service. The examiner further noted the Veteran’s reports of abdominal pain, pelvic pressure, and urinary frequency during service.  

In a July 2020 VA medical opinion, the examiner opined the Veteran’s condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated there was no evidence of cystitis in service and that she was unable to confirm a diagnosis of cystitis during service as there is no evidence of bladder infection in service treatment records. The examiner did not consider the Veterans reports or the noted abdominal pain in service. 

In another July 2020 VA medical opinion, the same examiner opined the Veteran’s condition is at least as likely as not proximately due to or the result of the Veteran’s service connected condition. The examiner noted the Veteran’s abdominal pain is a complaint that patients have with cystitis. The examiner further stated the Veteran’s abdominal pain is secondary to the cystitis. The examiner cited medical journals demonstrating the causes of abdominal pain in adults. 

Thus, the question becomes whether the current disability is related to service.  On this question there are probative opinions in favor of and against the claim.

Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current cystitis is related to service.  Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for cystitis is warranted.  38 U.S.C. § 5107; 38 C.F.R. § 3.102.

REASONS FOR REMAND

1. Entitlement to service connection for
 pain is secondary to the cystitis. The examiner cited medical journals demonstrating the causes of abdominal pain in adults. 

Thus, the question becomes whether the current disability is related to service.  On this question there are probative opinions in favor of and against the claim.

Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current cystitis is related to service.  Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for cystitis is warranted.  38 U.S.C. § 5107; 38 C.F.R. § 3.102.

REASONS FOR REMAND

1. Entitlement to service connection for unspecified fatigue is remanded.

In a September 2019 Board decision, the matter of unspecified fatigue was remanded for an addendum opinion. The decision states the addendum opinion should be obtained to address whether the Veteran’s fatigue is at least as likely as not related to his active service, to include exposure to environmental hazards in Southwest Asia. 

The RO requested an addendum opinion in December 2019. The RO did not include exposure to environmental hazards in Southwest Asia in the requested addendum opinion. 

An addendum opinion was completed in December 2019. The clinician notes the Veteran has multiple medical conditions which may present with fatigue. The clinician also notes the Veteran’s current fatigue appears to be related to multiple non-service related conditions. The clinician did not provide a clear rationale to his opinion. The nexus opinion, as stated, thus lacks the degree of certainty required for medical nexus evidence. See Hood v. Shinseki, 23 Vet. App. 295, 299 (2009).

The matters are REMANDED for the following action:

1. Request an addendum opinion with another examiner to determine the nature and etiology of the claimed unspecified fatigue \condition.  The examiner must review the entire claims file, including a copy of this remand.

The examiner should then record all noted signs and reported symptoms, document all clinical findings, and provide a diagnosis if possible.

The examiner is asked to provide responses to the following:

A)	Identify the Veteran’s objective indications of a disability.

“Objective indications” of a qualifying chronic disability include both objective evidence perceptible to an examining physician and other non-medical indicators that are capable of independent verification.  38 C.F.R. § 3.317(a)(3).  Non-medical indicators include evidence such as time lost form work, the veteran having sought treatment for his symptoms, and change in the veteran’s appearance, physical abilities, and mental or emotional attitude.  By history, physical examination, or laboratory testing, can the Veteran’s objective indications of a disability be attributed to a known clinical diagnosis?

If the signs and symptoms are not characteristic of a known clinical diagnosis, the examiner should so indicate.  There is no requirement that the examiner provide a diagnosis of undiagnosed illness.

B)	If the Veteran’s objective indications cannot be attributed to a known clinical diagnosis, is there affirmative evidence that the undiagnosed illness is not incurred during active service during the Persian Gulf War or that it was caused by a supervening condition or event that occurred since the Veteran’s departure from service during the Persian Gulf War?

The examiner should note that a positive response to this question requires affirmative evidence.  The mere absence of evidence is not sufficient.

C)	If the Veteran’s objective indications can be attributed to a known clinical diagnosis, is the etiology of the Veteran’s condition (1) inconclusive, (2) partially understood, or (3) fully understood?

This determination as to each must be based on the Veteran’s specific case and cannot be based on the etiology of the disease or disability population as a whole.

D)	If the Veteran’s objective indications can be attributed to a known clinical diagnosis, is the pathophysiology of the Veteran’s condition (1) inconclusive, (2) partially understood, or (3) fully understood?

This determination as to each must be based on the Veteran’s specific case and cannot be based on the pathophysiology of the disease or disability population as a whole.

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E)	If both the etiology and pathophysiology are partially understood or fully understood, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s diagnosed condition was incurred in, or is otherwise related to, his active service?

A complete rationale must be provided for all opinions expressed. If any requested opinion cannot be provided without resort to speculation, the medical professional should state and explain why an opinion cannot be provided without resort to speculation.

 

 

K. J. ALIBRANDO

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	M. Lang, Attorney Advisor