ERECTILE DYSFUNCTION

Summary

The Veteran served from August 1986 to February 1989. The Veteran appeals the denial of service connection for erectile dysfunction (ED) and a lower extremity neurological disorder, and seeks remand for benign prostatic hyperplasia (BPH). The Board granted service connection for ED, finding it was secondary to the Veteran's service-connected spine cord injury at T-6 with lumbar degenerative joint disease. The Board found the April 2025 VA positive nexus opinion probative, despite a factual inaccuracy regarding the timing of the ED's onset, as it provided a reasoned medical explanation linking the spine injury and degenerative changes to ED. The Board denied service connection for a lower extremity neurological disorder, finding no current diagnosis, signs, or symptoms to support it, despite some prior notations of numbness and tingling. The Board gave more weight to specific neurological examinations over general notations. The case was remanded for BPH due to inadequate medical opinions, as existing opinions were conclusory, misapplied rationales, or failed to provide aggravation opinions for secondary service connection. The Board considered the benefit of the doubt doctrine for ED but found it inapplicable to the denied lower extremity neurological disorder claim as the evidence weighed against it.

Rationale

Positive nexus opinion found probative despite factual inaccuracy.; Spine injury and degenerative changes linked to ED.; Benefit of the doubt applied due to equipoise.

Full Decision Text

Citation Nr: 26004996
Decision Date: 04/28/26	Archive Date: 04/28/26

DOCKET NO. 14-44 053A
DATE: April 28, 2026

ORDER

Service connection for erectile dysfunction (ED) is granted.

Service connection for a lower extremity neurological disorder is denied.

REMANDED

Entitlement to service connection for benign prostatic hyperplasia (BPH) is remanded.

FINDINGS OF FACT

1. The Veteran's ED is caused by his service-connected spine cord injury around T-6 with slight limitation of motion now with lumbar degenerative joint disease (spine disability).

2. The evidence of record does not demonstrate the existence of a current lower extremity neurological disorder.

CONCLUSIONS OF LAW

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

2. The criteria for service connection for a lower extremity neurological disorder are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from August 1986 to February 1989.

This case comes before the Board of Veterans' Appeals (Board) from a September 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO), hereinafter the Agency of Original Jurisdiction (AOJ), which, in pertinent part, denied service connection for erectile dysfunction and bowel and bladder dysfunction. The issue of service connection for a lower extremity neurological disorder was added to the appeal from the November 2022 Board Remand as a result of the August 2013 VA examiner noting the Veteran had "diminished foot proprioception" associated with his spine disability.

In his December 2014 substantive appeal (VA Form 9), the Veteran declined the opinion for a hearing on the first page of the appeal, but then requested a local hearing with a Decision Review Officer (DRO) on the Appeal Hearing Options page. In a January 2015 Statement in Support of Claim, the Veteran seemingly requested a hearing, stating his power of attorney (POA) would submit the paperwork; however, the January 2015 Correspondence from the Veteran's POA stated that after speaking with the Veteran, the Veteran wished to continue under the DRO process, but did not want a hearing on the matter. Subsequently, an August 2022 VA letter stated the Veteran had requested an optional Board hearing and that this may add to the wait time in the issuance of a decision. In September 2022, the Veteran submitted a signed withdrawal of his hearing request. See September 19, 2022 and September 26, 2022 Correspondence. As such, the Veteran's request for a hearing is considered withdrawn. 38 C.F.R. § 20.704(d). Accordingly, the Board will proceed with adjudication of the appeal at this time.

By way of additional background, the Board remanded the case in January 2020, November 2022, and August 2024. The case now returns to the Board for appellate review. In this regard, the August 2024 Board remand, in relevant part, included directives to associate with the claims file any missing VA treatment record prior to October 2014 and associate the documents in VistA with the claims file, referencing certain dates. The Board finds this has been accomplished. See CAPRI Records, Medical Treatment Records, and November 2024 Finding of Unavailability. As such, the Board concludes that that the Board's remand orders have been substantially complied with, and it may proceed with a decision at this time. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002).

Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (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 disease or injury incurred or aggravated during service. Shedden v.
 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002).

Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty from active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (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 disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury.  38 C.F.R. § 3.310(a).  Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability results from the service-connected disability.  38 U.S.C. §§ 1110, 1131; Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023) (holding that section 1110 "requires compensation when a service-connected disease or injury is a but-for cause of a present-day disability").

ED

The Veteran has a current diagnosis of ED. See August 2013 VA examination, February 2020 VA examination, and January 2025 VA examination. Additionally, the Veteran is service connected for a spine cord injury around T-6 with slight limitation of motion now with lumbar degenerative joint disease. See April 1989 Rating Decision and October 2025 Codesheet. Thus, the first two elements of service connection on a secondary basis are met.

Regarding the third element of service connection-a nexus-the April 2025 VA positive nexus medical opinion for ED states,

Erectile dysfunction in individuals with spinal cord injuries is a well-documented phenomenon, particularly in cases where the injury involves the thoracic spine, such as at the T-6 level. The T-6 spinal injury, which affects the sympathetic nervous system pathways involved in sexual function, can impair the neurovascular mechanisms required for erection. Studies have shown that spinal cord injuries at or above the T-6 level disrupt sympathetic signals, which are crucial for the physiological process of achieving an erection (Finkelstein et al., 2021). In the veteran's case, the medical records indicate a direct correlation between the spinal cord injury and the onset of ED, with the condition appearing shortly after the injury occurred. This supports the conclusion that the veteran's ED is not merely coincidental, but rather a direct consequence of the neurological impairment caused by the spinal cord injury.

Furthermore, the veteran's lumbar degenerative joint disease may have compounded this issue. Degenerative changes in the lumbar spine can result in increased pain and decreased mobility, leading to physical and psychological stress, both of which are known contributors to erectile dysfunction (Hoch et al., 2019). The records show that the veteran's lumbar condition has resulted in chronic pain, which could further hinder sexual function due to both physical discomfort and the psychological burden associated with chronic pain syndromes (Wright et al., 2019). The interaction between the spinal injury, lumbar degeneration, and the development of ED is consistent with the medical understanding that musculoskeletal pain and spinal injuries, particularly in the thoracic and lumbar regions, can disrupt the neural pathways and increase the risk for erectile dysfunction.

While this opinion states that the Veteran's ED began shortly after the underlying cervical spine injury occurred, which is factually inaccurate, the opinion still demonstrates a relationship between ED and the spine disability in that disruption of the neural pathways and chronic pain result in difficulty achieving an erection. Despite the noted inaccurate fact, the Board finds this medical opinion to be of probative value because even without that fact the opinion still holds true, and it contains a reasoned medical explanation with clear conclusions and supporting data. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("[E]ven if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight."); Stefl v. Nicholson, 21 Vet. App. 120, 
 factually inaccurate, the opinion still demonstrates a relationship between ED and the spine disability in that disruption of the neural pathways and chronic pain result in difficulty achieving an erection. Despite the noted inaccurate fact, the Board finds this medical opinion to be of probative value because even without that fact the opinion still holds true, and it contains a reasoned medical explanation with clear conclusions and supporting data. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("[E]ven if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight."); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding a medical opinion must contain clear conclusions with supporting data, and a reasoned medical explanation connecting the two); Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005); Guerrieri v. Brown, 4 Vet. App. 467 (1993).

Additionally, the June 2025 medical opinion (regarding the cervical spine) and the August 2025 medical opinion (regarding irritable bowel syndrome) state, in pertinent part, "Thoracic injuries are reported to result in lower extremity sensorimotor deficits, bowel, bladder and sexual dysfunction, trunk motor weakness which produce postural difficulties. (Emmady et al, 2025)." In this regard, the cited medical literature shows thoracic injuries result in sexual dysfunction and aligns with the positive nexus medical opinion in April 2025.

As for the negative nexus medical opinions, the Board finds they are inadequate. First, there is no medical opinion for the Veteran's ED in August 2013, despite a VA examination and diagnosis of ED.

The March 2020 secondary service connection medical opinions state that the Veteran's ED was not related to his spine condition or hypertensive medication, and provides a rationale related to the hypertensive medication only. First and foremost, there is no rationale for ED as it relates to the spine condition, which was the focus of the requested medical opinion. Furthermore, the Veteran is not service connected for hypertension, and thus the medical opinion should not have detailed a rationale based on the medication for nonservice-connected hypertension. See Nieves-Rodriguez, supra; Stefl, supra; Guerrieri, supra; Hernandez-Toyens, supra.  Moreover, the March 2020 direct service connection opinion is conclusory. Id.

The July 2023 medical opinions provide facts related to the Veteran's case, but do not provide any real rationale other than stating that, "Records show a correlation between his development of BPH and his diagnosis of erectile dysfunction. There is no evidence to relate his erectile dysfunction, which started more than 20 years after his injury, to his service-connected back injury. Therefore, I am unable to create nexus between his erectile dysfunction and his service-connected injury." Id.

The April 2025 and June 2025 opinions do not include the Veteran's lay statements nor does, nor do they include an aggravation opinion. Id., Atencio v. O'Rourke, 30 Vet. App. 74, 90 (2018) (holding that, in claims involving service connection on a secondary basis, VA medical opinions must provide separate findings and rationales regarding both causation and aggravation).

The August 2025 addendum medical opinion states,

An article published by University of Utah Health on "Sex After a Spinal Cord Injury" suggests that sexual dysfunction following a spinal cord injury is temporary, with a 100% chance of regaining sexual ability - that is have an erection again. Psychogenic erectile dysfunction - that is absence of psychological stimulus which travel down the brain through to T11 - L2 of the spinal cord - that is, T11-L2 injury is involved. Meanwhile, reflex erectile dysfunction is experienced when there is spinal cord injury involving S2- S4. Thus based on this understanding, it is less likely than not that the condition of ED stemmed from around T6 spinal cord injury.

However, this misinterprets the article's statements in that the article actually explains there is the chance of regaining an erection with medication. Additionally, this does not include an aggravation opinion for secondary service connection. See Atencio, supra.

The September 2025 addendum medical opinion is conclusory. See Stefl, supra.

In sum, the Board finds the competent, credible, and probative evidence is at least in equipoise as to whether the Veteran's ED is caused by his service-connected spine disability; accordingly, the Board finds that service connection is warranted for ED on this basis. See 38 C.F.R. § 3.310; Lynch v. McDonough, 21 F.4th 776 (
However, this misinterprets the article's statements in that the article actually explains there is the chance of regaining an erection with medication. Additionally, this does not include an aggravation opinion for secondary service connection. See Atencio, supra.

The September 2025 addendum medical opinion is conclusory. See Stefl, supra.

In sum, the Board finds the competent, credible, and probative evidence is at least in equipoise as to whether the Veteran's ED is caused by his service-connected spine disability; accordingly, the Board finds that service connection is warranted for ED on this basis. See 38 C.F.R. § 3.310; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).  In so reaching that conclusion, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch, supra; Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001).

Lower Extremity Neurological Disorder

As noted above, the issue of service connection for a lower extremity neurological disorder was added to the appeal from the November 2022 Board Remand due to the August 2013 VA examiner's notation of "diminished foot proprioception" associated with his back disability.

The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that §§ 1110 and 1131's requirement of the existence of a present disability for VA compensation purposes cannot be considered arbitrary); see also McClain v. Nicholson, 21 Vet. App. 319, 323 (2007) (holding that the requirement of a current disability is met when a claimant has a disability at the time a claim for VA compensation is filed or during the pendency of that claim).

The Board finds that there is no current diagnosis or any symptomatology to warrant service connection for a lower extremity neurological disorder.

To begin, the Board notes that there is evidence of numbness and tingling in the lower extremities, including tingling in "elevated" lower extremities, in 1988 and 1989, following his motor vehicle accident. See Regional Medical Center Treatment Records, Dr. J.K, MD notations, Service Treatment Records (STRs), November 1989 VA Examination, and VAMC Memphis Treatment Records. However, these occurrences are prior to the appeal period in this case and do not qualify as a current disability for the purposes of the first element of service connection.

Specifically, in terms of peripheral nerve tests during the appeal period, in November 2012, during a neurosurgery consultation concerning complaints for the neck and upper extremity, the Veteran's lower extremity motor power was noted as 5/5, and it was noted there was no loss of sensation to the lower extremities.

In the February 2020 VA spine examination, the VA examiner did not find any signs or symptoms of radiculopathy, and the straight leg tests were negative.

In the July 2023 VA peripheral nerves examination, for a lower extremity neurological disorder, the VA examiner found no symptoms, no signs, normal muscle strength, no muscle atrophy, normal reflexes, normal sensory, normal gait, and no assistive devices for the Veteran. In the remarks section, the VA examiner stated,

For the claimant's claimed condition of Right Lower Extremity Neurological Disorder there is no diagnosis because there are no findings, signs and or symptoms to support a diagnosis. For the claimant's claimed condition of Left Lower Extremity Neurological Disorder there is no diagnosis because there are no findings, signs and or symptoms to support a diagnosis. Veteran denies any lower extremity radiculopathy and states his only lower extremity issue is some occasional left ankle pain that he relates to getting in and out of his mail truck for many years.

In the January 2025 VA peripheral nerves examination, in terms of onset, the Veteran stated it was mid-2000s and he experienced radiation from the back around the waist to the front, but there was no radiation down his legs. He stated his legs would go to sleep if he sat too long, but otherwise denied numbness, tingling, or burning to the bilateral lower extremities. In terms of current symptoms, it was noted the Veteran continued to deny any pain, tingling, or numbness that radiates down the bilateral lower extremities. The VA examiner found no symptoms, no signs, normal muscle strength, no muscle atrophy, normal reflexes, normal sensory, normal gait, no assistive devices
 years.

In the January 2025 VA peripheral nerves examination, in terms of onset, the Veteran stated it was mid-2000s and he experienced radiation from the back around the waist to the front, but there was no radiation down his legs. He stated his legs would go to sleep if he sat too long, but otherwise denied numbness, tingling, or burning to the bilateral lower extremities. In terms of current symptoms, it was noted the Veteran continued to deny any pain, tingling, or numbness that radiates down the bilateral lower extremities. The VA examiner found no symptoms, no signs, normal muscle strength, no muscle atrophy, normal reflexes, normal sensory, normal gait, no assistive devices, and no objective evidence to support a lower extremity neurological disorder.

While there are notations during the appeal period of "Pain in joint involving lower leg" in the 2013, 2014, and 2015 CAPRI Records, and "diminished foot proprioception" in the August 2013 VA spine examination, these symptoms do not necessarily indicate a neurological disorder. See CAPRI Records and August 2013 VA examination. Furthermore, the Board gives more weight to the evaluations performed by the medical professionals who specifically tested and examined the Veteran for a peripheral nerve disorder rather than simple notations of leg or foot issues. See Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue).

Moreover, the Board notes that the Veteran has not endorsed a lower extremity neurological disorder. In fact, the Veteran stated that "his only lower extremity issue is some occasional left ankle pain that he relates to getting in and out of his mail truck for many years." See July 2023 VA Peripheral Nerves Examination. The Veteran also stated in terms of onset in the mid-2000s, there was no radiation down his legs, no numbness, tingling, or burning to the bilateral lower extremities, and in terms of current symptoms, there was no pain, tingling, or numbness that radiated down the bilateral lower extremities. See January 2025 VA Peripheral Nerves Examination.

The Board has considered the medical evidence of record, including any symptomatology during the appeal period, however, there are no signs or symptoms, no positive test results, and no complaints to warrant the diagnosis of a current lower extremity neurological disorder. The Board has also considered that symptoms that cause functional impairment can qualify as a disability for VA compensation purposes. See Saunders v. Wilkie, 886 F.3d 1356 (2018) (despite lack of a formal diagnosis, symptoms may count as a disability for VA compensation purposes if they cause functional impairment). However, as the medical examiners have indicated, there are no signs or symptoms that would relate to a lower extremity neurological disorder; thus, the Board finds this avenue has been adequately explored and satisfied. Id.

In sum, the Veteran does not have a diagnosis of a lower extremity neurological disorder, or symptoms attributable to such. Therefore, service connection is not warranted for a lower extremity neurological disorder; the claim must therefore be denied based on the evidence of record in this appeal. See 38 C.F.R. §§ 3.303, 3.317(a)(1); McClain, supra; Saunders, supra; Brammer v. Derwinski, 3 Vet. App. 223 (1995) (Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability). 

In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch, supra; Ortiz, supra.

REASONS FOR REMAND

The Board finds that there are no adequate medical opinions for the Veteran's BPH.

The August 2013 medical opinion was intended to be a secondary service connection opinion, but the rationale only addresses direct service connection.  See Robinson v. Peake, 21 Vet. App. 545, 552 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (recognizing VA's duty to consider all issues raised either by the claimant or by the evidence of record).  

The March 2020 medical opinions are overall conclusory, rely on lack of evidence in the STRs in reaching the conclusions, and the two opinions that
 Board finds that there are no adequate medical opinions for the Veteran's BPH.

The August 2013 medical opinion was intended to be a secondary service connection opinion, but the rationale only addresses direct service connection.  See Robinson v. Peake, 21 Vet. App. 545, 552 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009) (recognizing VA's duty to consider all issues raised either by the claimant or by the evidence of record).  

The March 2020 medical opinions are overall conclusory, rely on lack of evidence in the STRs in reaching the conclusions, and the two opinions that were intended to be secondary service connection opinions actually have direct service connection rationales. See Stefl, supra; Dalton v. Nicholson, 21 Vet. App. 23 (2007).

The July 2023 medical opinions and the August 2025 addendum medical opinion provide facts related to the Veteran's case, but do not provide any real rationale other than stating that "There is no evidence to relate his benign prostatic hyperplasia status post urolift procedure with residuals of bowel and bladder disturbance, which started more than 20 years after his injury, to his service-connected back injury." Id.

The January 2025 medical opinion is conclusory. See Stefl, supra.

The August 2025 addendum medical opinion states,

BPH arises due to the loss of homeostasis between prostatic cellular proliferation and apoptosis or cell death. This imbalance favors cellular proliferation without intervention. The result is increased numbers of prostatic periurethral epithelial and stromal cells, which can be seen histopathologically. The etiology of BPH is influenced by a wide variety of risk factors, in addition to the direct hormonal effects of testosterone on prostate tissue. Men who are castrated before puberty or who have an androgen-related disorder do not develop BPH. (Ng et al., 2024). Some risk factors include: diabetes and the use of antidiabetic medications, genetic predisposition, localized inflammation, obesity, metabolic syndrome.

However, this does not include an aggravation opinion for secondary service connection. See Atencio, supra.

The September 2025 addendum medical opinion is conclusory. See Stefl, supra.

As such, there are no adequate medical opinions for the Veteran's BPH. Accordingly, remand is necessary in order to obtain adequate medical opinions for this disorder. Id.; Barr v. Nicholson, 21 Vet. App. 303, 311 (2007).

The matters are REMANDED for the following action:

Forward the claims file to an appropriate examiner, who has not previously participated in this case, to obtain an addendum opinion in order to determine whether the Veteran's BPH is related to service or a service-connected disability. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. A new examination may be ordered if deemed necessary; however, if the Veteran does not attend any scheduled examination related to this Remand, the examiner must provide the requested opinions below. If any requested opinion cannot be rendered, the examiner must explain why providing the opinion is not possible.

After review of the record (and examination if deemed necessary), the examiner should must opine whether the Veteran's identified BPH began in service, within one year of discharge therefrom, or is otherwise related to military service.

If a direct relationship is not found, the examiner must then opine whether the Veteran's BPH is (a) caused by; or (b) aggravated (i.e., worsened) by his service-connected disabilities, particularly his service-connected spine disability.

In addressing the above, the examiner should address any relevant medical articles herein. The examiner must also address any lay statements regarding onset of his symptomatology and the continuity of symptomatology since onset and/or since discharge from service.

All findings should be reported in detail and all opinions must be accompanied by a clear rationale. The examiner is reminded that a separate and distinct opinions with supporting rationale are required for all theories of entitlement addressed, including secondary causation and secondary aggravation.

 

MARTIN B. PETERS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Garfield, Jeannine F.

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.