PROSTATE GLAND DISEASE OF

Summary

The veteran, who served in the Army from June 1985 to August 1985 and again from October 1986 to June 1992, appeals the denial of service connection for benign prostatic hyperplasia (BPH) on a secondary basis. The veteran claimed BPH was secondary to his service-connected major depressive disorder, adjustment disorder with mixed disturbance of emotions and conduct, and diabetes mellitus. He submitted medical literature supporting a link between diabetes and BPH, and between anxiety/stress and prostate issues. The Board reviewed multiple VA opinions, noting inconsistencies and shortcomings, particularly in addressing the aggravation component of secondary service connection. One VA opinion found BPH less likely than not related to diabetes, while another found it less likely than not caused by toxic exposure. However, a statement from the veteran's treating psychiatrist, supported by treatise evidence, indicated that the veteran's anxiety symptoms could worsen urinary issues, suggesting BPH would have been less severe but for his service-connected mental disorders. The Board found this opinion, despite its brevity, sufficient to decide the claim, applying the "but-for" causation standard established in Spicer v. McDonough. Resolving all reasonable doubt in the veteran's favor, the Board found service connection for BPH warranted as secondary to his major depressive disorder and adjustment disorder.

Rationale

Existing current disability (BPH) established.; Aggravated by service-connected mental disorders (major depressive disorder, adjustment disorder).; Resolving doubt in veteran's favor per 38 C.F.R. § 3.102 and Spicer v. McDonough.

Full Decision Text

Citation Nr: A26036746
Decision Date: 04/21/26	Archive Date: 04/21/26

DOCKET NO. 250408-533270
DATE: April 21, 2026

ORDER

Service connection for benign prostatic hyperplasia (BPH), as secondary to service-connected disability major depressive disorder and adjustment disorder with mixed disturbance of emotions and conduct, is granted.

FINDING OF FACT

The Veteran's currently diagnosed BPH, is aggravated by (would have been less severe but for) the service-connected major depressive disorder and adjustment disorder with mixed disturbance of emotions and conduct.  

CONCLUSION OF LAW

Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for BPH, as secondary to service-connected major depressive disorder and adjustment disorder with mixed disturbance of emotions and conduct, have been met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310; Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023).  

REASONS AND BASES FOR FINDING AND CONCLUSION

The appellant is a Veteran who served on active duty in the Army from October 1986 to June 1992, with additional prior active service of three months and 23 days (June 1985 to August 1985 and from June 1986 to August 1986).  This case comes to the Board of Veterans' Appeals (Board) on appeal from an April 2025 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which is an agency of original jurisdiction (AOJ).  

In the April 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket.  Therefore, the Board may only consider the evidence of record at the time of the April 2025 AOJ decision on appeal.  38 C.F.R. § 20.301.  Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board.  38 C.F.R. §§ 20.300, 20.301, 20.801.  

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 claim, considering the new evidence in addition to the evidence previously considered.  Id.  Specific instructions for filing a Supplemental Claim are included with this decision.  

Entitlement to service connection for BPH, claimed as secondary to service-connected disability including major depressive disorder and adjustment disorder with mixed disturbance of emotions and conduct

The Veteran contends that his BPH is secondary to a service-connected disability.  On his December 2024 application, he asserted that it was secondary to his service-connected major depressive disorder and diabetes mellitus, the former of which has been service-connected since June 1995 (and evaluated as 100 percent since March 2007) and the latter of which has been service-connected since August 2023 (and evaluated as 20 percent since then).  On an accompanying statement, he stated that he was filing a claim for service connection for BPH on a secondary basis, due to his service-connected diabetes as well as his service-connected depression, anxiety, and stress.  He noted his symptoms included urinary frequency, slow urine flow at times, frequent nighttime urination, dribbling, and incontinence.  In support of his claim, he enclosed treatise evidence from the Mayo Clinic, showing a medical link between BPH and diabetes (it indicates that diabetes is a well-known risk factor for BPH).  

Subsequently, in February 2025, he submitted additional treatise evidence pertaining to a link between anxiety and prostate health; the medical article explained that constant stress and anxiety causes the body to release elevated levels of cortisol, which can lead to inflammation throughout the system including the prostate gland, which in turn may contribute to the development or worsening of prostate issues such as BPH.  In a March 2025 statement, he asserted that the VA opinions obtained to date were insufficient in part for failing to consider that his BPH was aggravated by service-connected disability.  (He also presented arguments about how a February 2025 VA TERA opinion was inadequate to decide his claim.)  In other statements in March 2025 and April 2025, he asserted that evidence from his treating psychiatrist linked his service-connected mental disorders to his BPH on an aggravation basis (and further
 article explained that constant stress and anxiety causes the body to release elevated levels of cortisol, which can lead to inflammation throughout the system including the prostate gland, which in turn may contribute to the development or worsening of prostate issues such as BPH.  In a March 2025 statement, he asserted that the VA opinions obtained to date were insufficient in part for failing to consider that his BPH was aggravated by service-connected disability.  (He also presented arguments about how a February 2025 VA TERA opinion was inadequate to decide his claim.)  In other statements in March 2025 and April 2025, he asserted that evidence from his treating psychiatrist linked his service-connected mental disorders to his BPH on an aggravation basis (and further posited that his service-connected diabetes also worsened his BPH).  The Veteran maintained that the decision on his claim should be resolved in his favor in light of the positive and negative evidence on file.  

Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304.  

Service connection is also warranted for disability which is proximately due to, or the result of, service-connected disease or injury.  38 C.F.R. § 3.310(a).  Further, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury, will be service-connected.  38 C.F.R. § 3.310(b).  

The United States Court of Appeals for the Federal Circuit clarified the standard for secondary service connection, essentially invalidating the regulation definitions.  Spicer v. McDonough, 61 F.4th 1360, 1365 (Fed. Cir. 2023).  

Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability.  38 C.F.R. § 3.310(a)-(b).  Secondary causation exists when, but for the service-connected disability, the non-service-connected disability was caused by a service-connected disability either in a direct, etiological way or via multiple steps in a causal chain. Spicer v. McDonough, 61 F.4th 1360, 1365 (Fed. Cir. 2023) (citations omitted).  

Secondary aggravation exists when the nonservice-connected disability not caused by a service-connected disability would be less severe and result in less functional impairment but for a service-connected disability.  Id. at 1364.  For example, secondary aggravation may be established where the natural progression of the non-service-connected disability could have been arrested or improved but for the service-connected disability.  Id.  In essence the Federal Circuit in Spicer held that proximate causation is not the standard for secondary service connection.  Rather, "but for" causation is the standard, which is broader than proximate causation.  

It is the defined and consistently applied policy of the VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case.  When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant.  By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim.  38 C.F.R. § 3.102.  

After applying the pertinent criteria to the facts in the record, the Board concludes that, by resolving reasonable doubt in the Veteran's favor, he has a current disability, diagnosed as BPH, that is aggravated by (would have been less severe but for) his service-connected major depressive disorder and adjustment disorder with mixed disturbance of motions and conduct.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.102, 3.310(a); Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023).    

It is not in dispute that the Veteran has a diagnosis of BPH.  On VA examination in January 2025, the diagnosis was BPH.  Thus, the initial requisite element of an existing current disability has been shown.  

The next inquiry for establishing
 current disability, diagnosed as BPH, that is aggravated by (would have been less severe but for) his service-connected major depressive disorder and adjustment disorder with mixed disturbance of motions and conduct.  38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.102, 3.310(a); Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023).    

It is not in dispute that the Veteran has a diagnosis of BPH.  On VA examination in January 2025, the diagnosis was BPH.  Thus, the initial requisite element of an existing current disability has been shown.  

The next inquiry for establishing service connection on a secondary basis is whether the current disability was caused or aggravated by a service-connected disability.  There are several VA medical opinions that address this issue.  

A January 2025 opinion indicates that the Veteran's BPH was at least as likely as not proximately due to or the result of his service-connected diabetes mellitus.  The rationale was that increasing epidemiologic evidence suggested that diabetes mellitus significantly increases the risks of BPH.  The examiner cited supportive medical literature but did not address whether BPH was secondary to the service-connected major depressive disorder and adjustment disorder.   The VA, however, subsequently sought an addendum opinion given the existence of evidence showing that the Veteran had urinary issues which preceded his diabetes mellitus.  

A February 2025 addendum opinion by a different examiner indicates that the Veteran's BPH was less likely than not proximately due to or the result of his service-connected diabetes mellitus.  The examiner stated that BPH preceded the onset of diabetes mellitus type II in 2020.  (A review of the treatment records, however, shows the Veteran had various urinary issues to include hematuria from the 1990s and a suggestion of a mildly enlarged prostate from an IVP conducted in 2005, but the records do not appear to reflect a confirmed diagnosis of BPH until 2023.)  Also, the examiner added, without citation to any source, that medical literature reviewed noted that there was no causal relationship between BPH and the service-connected major depressive disorder and adjustment disorder with mixed disturbances of emotion and conduct.  

A subsequent February 2025 opinion indicates that the BPH was less likely than not caused by the Veteran's toxic exposure risk activities (through his recognized service in Southwest Asia during the Persian Gulf War) after considering the total potential exposure through all applicable military deployments and the synergistic, combined effect of all TERAs.  The rationale was that the Veteran had risk factors outside of his military service, namely, age, genetics/family history, diabetes mellitus, metabolic syndrome, hypertension, sedentary lifestyle, and erectile dysfunction, that far outweighed the factors identified in the TERA.  The examiner, however, did not address the fact that the Veteran's list of service-connected disabilities included diabetes mellitus (since August 2023), hypertension (since 2006), and erectile dysfunction (since 2011).    

The Veteran sought opinions from his treating providers.  VA treatment records show that in March 2025, at a mental health clinic visit, the Veteran reported that he had ups and downs of his mood and anxiety based on his stress level.  He also reported lots of urinary frequency and asked his psychiatrist for a written statement about whether his anxiety could affect his urinary issues.  In a March 2025 statement, his psychiatrist asserted that the Veteran was under his care for diagnoses of PTSD and major depressive disorder.  The physician asserted that the Veteran's anxiety symptoms "can worsen urinary issues, particularly frequency of urination."  He briefly indicated that this occurred from the effects of stress hormones in the body.  (This explanation is supported by medical treatise evidence that the Veteran had furnished.)  Other VA treatment records in February 2025 and March 2025 show that the Veteran dropped off paperwork in the clinic and repeatedly followed up on his request for a statement from his primary care physician to the effect that there was a 50 percent or higher probability that his anxiety and depression had an effect on, or could have contributed to, his BPH.  (It is not clear if he was aware that his psychiatrist had supplied a similar statement to that effect for the record.)  In a brief note in late March 2025, which appears to have misconstrued the Veteran's request, his primary care physician stated that BPH symptoms certainly "could exacerbate depression. more likely than not." 

An April 2025 opinion indicates that the Veteran's BPH was less likely than not proximately due to or the result of his service-connected major depressive disorder and adjustment disorder with mixed disturbance of emotions and conduct.  The rationale was that the Veteran had BPH and overactive bladder, which
 that his anxiety and depression had an effect on, or could have contributed to, his BPH.  (It is not clear if he was aware that his psychiatrist had supplied a similar statement to that effect for the record.)  In a brief note in late March 2025, which appears to have misconstrued the Veteran's request, his primary care physician stated that BPH symptoms certainly "could exacerbate depression. more likely than not." 

An April 2025 opinion indicates that the Veteran's BPH was less likely than not proximately due to or the result of his service-connected major depressive disorder and adjustment disorder with mixed disturbance of emotions and conduct.  The rationale was that the Veteran had BPH and overactive bladder, which were two urological conditions that had no pathoanatomical or pathophysiological correlation to or causation with the service-connected mental disorders.  He stated that the mental disorders did not lead to BPH, which was a common condition in men as they aged.  He found the contentions by the Veteran and his psychiatrist were not supported by objective data and were speculative in nature.  The examiner (a family physician) did not provide an opinion as to whether the Veteran's BPH was aggravated by service-connected disability.  

In short, there is VA evidence both in favor of, and against the Veteran's claim.  The Board, however, acknowledges the shortcomings of the medical opinions.  For example, none of the opinions sought by the VA adequately addressed the aggravation component of the secondary service connection inquiry.  Rather, despite the Veteran's contentions regarding aggravation of his BPH by service-connected disabilities, the examiners only addressed the causation component.  VA-sought opinions were also not entirely complete because they either did not address or did not provide adequate rationale for all of the service-connected disabilities that were potentially related to BPH, to include the Veteran's mental disorder, diabetes mellitus type II, hypertension, and erectile dysfunction.  

Notwithstanding the foregoing, a VA opinion, which the Veteran sought from his treating psychiatrist, addresses aggravation of BPH by his mental disorder symptoms, which is corroborated by medical treatise evidence supplied by the Veteran.  Despite its brevity, the Board finds that it is sufficient to decide the claim at this time.  (The Board finds that remanding for another medical opinion would result in unnecessarily imposing additional burdens on VA with no potential benefit flowing to the Veteran.  See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991).)  The psychiatrist essentially expressed that the Veteran's BPH would have been less severe but for his anxiety symptoms.  That is, he suffered a worsening of BPH due to his service-connected major depressive disorder and adjustment disorder with mixed disturbance of motions and conduct.  In that regard, it is noted that the Veteran's current service-connected mental impairment includes symptoms of anxiety.  See, e.g., July 2014 VA examination report, reflecting diagnoses of major depressive disorder and adjustment disorder with mixed disturbance of motions and conduct and enumerating his symptoms for VA rating purposes, which include anxiety (the examiner specifically noted that the Veteran did not have a diagnosis of PTSD but had adjustment disorder that was proximately due to his identified in-service stressors).   

After a review of the record and consideration of pertinent caselaw, the Board finds the evidence to be in approximate balance as to whether the Veteran's BPH is a "result of" his service-connected major depressive disorder and adjustment disorder with mixed disturbance of motions and conduct under the application of the broader "but-for" causation standard of 38 U.S.C. § 1110 that was adopted by the Spicer Court.  Accordingly, after resolving all doubt in favor of the Veteran, service connection for BPH is warranted as secondary to the service-connected major depressive disorder and adjustment disorder with mixed disturbance of motions and conduct under 38 C.F.R. § 3.310 and pursuant to Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023).  38 U.S.C. § 5107; 38 C.F.R. § 3.102.  

 

 

L. B. CRYAN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Breitbeil, Debbie

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.