RECTUM AND ANUS IMPAIRMENT OF SPHINCTER CONTROL

Summary

The Veteran served in the U.S. Army from January 2011 to August 2011, with additional service in the U.S. Army Reserve. The Veteran appealed the denial of service connection for hemorrhoids and attention deficit hyperactivity disorder (ADHD), and the remand of a hysterectomy claim. The Board granted service connection for hemorrhoids, finding that while nexus evidence was in equipoise, the benefit of the doubt was resolved in the Veteran's favor due to favorable findings of an in-service event and a positive nexus opinion. The Board denied service connection for ADHD as a separate disability, concluding that the Veteran's attention and concentration symptoms were already compensated through her service-connected PTSD and major depressive disorder, and that the evidence weighed against a separate ADHD diagnosis. The claim for a hysterectomy was remanded due to a duty-to-assist error; the prior VA opinion inadequately addressed both causation and aggravation for secondary service connection, and the Board instructed a new opinion to consider these factors, including the relationship to PTSD and military sexual trauma (MST).

Rationale

Favorable findings of in-service event and positive nexus opinion; Evidence of current diagnosis and in-service rectal pain; Relative equipoise on nexus, resolved in Veteran's favor

Full Decision Text

Citation Nr: A26037971
Decision Date: 04/22/26	Archive Date: 04/22/26

DOCKET NO. 241227-504137
DATE: April 22, 2026

ORDER

Entitlement to service for hemorrhoids is granted.

Entitlement to service connection for attention deficit hyperactivity disorder (ADHD), as a psychiatric disability separate from service connected posttraumatic stress disorder (PTSD) with major depressive disorder (MDD), is denied.

REMANDED

Entitlement to service connection for hysterectomy is remanded.

FINDINGS OF FACT

1. Resolving reasonable doubt in favor of the Veteran, it is at least as likely as not that her current hemorrhoid condition is causally related to her active service.  

2. The Veteran does not have an ADHD disorder that is separate and distinct from her service-connected PTSD with MDD and her attention and concentration symptoms are already being compensated through her currently service-connected psychiatric disability rating.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a hemorrhoids disability are met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for entitlement to service connection for ADHD, separate and distinct from the currently service-connected psychiatric disorder, have not been met.  38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from January 2011 to August 2011.  She has additional service in in the U. S. Army Reserve.   

The rating decisions on appeal were issued in April 2024 (service connection for a hysterectomy) and December 2024 (service connection for hemorrhoids and service connection for ADHD).  They are initial decisions; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In the December 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket.

The December 2024 Notice of Disagreement identified the Veteran's appeal of an April 2024 rating decision which denied entitlement to service connection for a hysterectomy.  As to this claim, the Veteran initially requested Higher-Level Review when submitting a May 2023 VA Form 20-0996, Decision Review Request: Higher-Level Review.  In August 2023, the Higher-Level Reviewer determined that there had been a duty to assist error and transferred the claim to the Supplemental Claim decision review option for additional development.  Therefore, the Board may only consider the evidence of record at the time of the April 2024 agency of original jurisdiction (AOJ) supplemental claim decision on appeal.  38?C.F.R. § 20.301. If evidence was submitted after the AOJ issued the supplemental claim decision on appeal, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300,?20.301, 20.801. 

The December 2024 Notice of Disagreement attempted to appeal an October 2023 (notification in November 2023) rating decision denying entitlement to service connection for ADHD and November 2022 and February 2023 rating decisions which denied entitlement to service connection for hemorrhoids.  The December 2024 Notice of Disagreement is not timely filed as to those rating decisions.  However, as these claims were subsequently denied in a December 2024 supplemental rating decision (entered following a May 2024 supplemental claim).  Reviewing the December 2024 Notice of Disagreement in the light most favorable to the Veteran, it is accepted as a timely appeal of the December 2024 supplemental claim rating decision as to these issues.  Therefore, the Board may only consider the evidence of record at the time of the December 2024 agency of original jurisdiction (AOJ) supplemental claim decision on appeal.  38 C.F.R. § 20.301.  If evidence was submitted after the AOJ issued the December 2024 supplemental claim decision on appeal, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300,?20.301, 20.801.

The December 2024 Notice of Disagreement also identified appeal issues of entitlement to service connection for bilateral tinnitus (as denied in a January 2020 rating decision) and entitlement to service connection for PTSD (as denied in a June 2014 rating decision).  The December 2024 Notice of Disagreement was not timely filed as to
 of original jurisdiction (AOJ) supplemental claim decision on appeal.  38 C.F.R. § 20.301.  If evidence was submitted after the AOJ issued the December 2024 supplemental claim decision on appeal, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300,?20.301, 20.801.

The December 2024 Notice of Disagreement also identified appeal issues of entitlement to service connection for bilateral tinnitus (as denied in a January 2020 rating decision) and entitlement to service connection for PTSD (as denied in a June 2014 rating decision).  The December 2024 Notice of Disagreement was not timely filed as to these rating decisions.  Additionally, service connection for bilateral tinnitus was granted in a December 2024 supplemental rating decision and service connection for PTSD was granted in a May 2020 rating decision.  These rating decisions are complete grants as to the service connection claims.  The issues of entitlement to service connection for bilateral tinnitus and for PTSD are no longer in appellate status and they are not addressed below.  

Finally, the December 2024 Notice of Disagreement sought to appeal the issue of "amnesia (multiple types)" as denied in a November 2023 rating decision.  However, the October 2023 rating decision (with notification to the Veteran in November 2023) did not address a claim for amnesia.  On review of the claims file, there is no prior decision as to amnesia.  This issue is not in appellate status, and it is not addressed below. 

As to entitlement to service connection for hemorrhoids and entitlement to service connection for ADHD, 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 or 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. 

However, because the Board is remanding the claim of entitlement to service connection for a hysterectomy, any evidence the Board could not consider will be considered by the AOJ in the adjudication of this claim.  38 C.F.R. § 3.103(c)(2)(ii).

1. Entitlement to service connection for hemorrhoids

Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303.

Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability.  Shedden v. Principi, 381 F.3d  163, 1167 (Fed. Cir. 2004).

The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight.  Wood v. Derwinski, 1 Vet. App. 190 (1991); Washington v. Nicholson, 19 Vet. App. 362 (2005).

When there is an approximate balance of positive and negative evidence regarding any material issue, reasonable doubt will be resolved in favor of the claimant.  See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (holding evidence is not in approximate balance, or nearly equal, when the evidence "persuasively favors one side or the other").

The Veteran seeks entitlement to service connection for hemorrhoids.  A February 2023 rating decision denied the claim but the decision included favorable findings that an in-service event occurred and there is a positive nexus opinion linking the claimed hemorrhoids disability and the Veteran's active service.  The December 2024 rating decision includes favorable findings that there is a current hemorrhoid diagnosis and a qualifying in-service event.  These favorable findings are binding on the Board.  Read together, the favorable findings warrant entitlement to service connection.  See Shedden supra. 

The Board additionally finds, on review of the claims file, the elements of service connection are shown.  Here, the Veteran's service treatment records confirm March 2011 treatment for rectal pain.  In May 2022 and November 2024, VA rectum and anus conditions examinations were provided.  As medical history, the exam
 an in-service event occurred and there is a positive nexus opinion linking the claimed hemorrhoids disability and the Veteran's active service.  The December 2024 rating decision includes favorable findings that there is a current hemorrhoid diagnosis and a qualifying in-service event.  These favorable findings are binding on the Board.  Read together, the favorable findings warrant entitlement to service connection.  See Shedden supra. 

The Board additionally finds, on review of the claims file, the elements of service connection are shown.  Here, the Veteran's service treatment records confirm March 2011 treatment for rectal pain.  In May 2022 and November 2024, VA rectum and anus conditions examinations were provided.  As medical history, the examiners noted the Veteran's report that her hemorrhoids were onset while she was deployed to Cuba in 2011.  The Veteran is competent to report hemorrhoid symptoms such as rectal pain.  An in-service event is shown.  The May 2022 examination report did not list a current diagnosis of hemorrhoids on the examination report, however, the examiner's opinion confirmed a current diagnosis.  The November 2022 examination report diagnosed hemorrhoids. A current diagnosis is shown.  The May 2022 examiner opined the Veteran's hemorrhoids were at least as likely as not causally related to her active service because they were initially onset in 2011 when the Veteran was deployed to Cuba.  The November 2024 VA examiner opined a hemorrhoid disability was less likely than not causally related to the Veteran's active service because the current rectal examination was normal and hemorrhoids were first diagnosed in March 2016.  As the evidence related to nexus is in relative equipoise, the Board resolves reasonable doubt in favor of the Veteran.  Thus, it is at least as likely as not that her current hemorrhoid disability is causally related to her in-service rectal pain symptoms.  A grant of entitlement to service connection is warranted.  Id; 38 U.S.C. § 1110; 38 C.F.R. § 3.303; see also Lynch supra.

2. Entitlement to service connection for ADHD

When a Veteran files a claim for VA benefits, he or she is seeking service connection for symptoms, regardless of how those symptoms are diagnosed or labeled.  Clemons v. Shinseki, 23 Vet. App. 1 (2009).  Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not "duplicative of or overlapping with the symptomatology" of the other condition.  Esteban v. Brown, 6 Vet. App. 259, 262 (1994).  However, pyramiding, which is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a Veteran's service-connected disability.  38 C.F.R. § 4.14.  PTSD, MDD, and additional acquired psychiatric disorders, to include ADHD are rated under the same rating criteria.  See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders.

Service connection is established for a psychiatric disorder of PTSD with MDD.  The Veteran seeks entitlement to service connection for an additional psychiatric disability, ADHD.  

Review of the claims file shows, in June 2023, the Veteran's VA primary care provider noted her reports of problems with focusing.  He referred her to a mental health provider for evaluation of possible ADHD.  In July 2023 VA psychiatry consult note confirms the Veterans history of MDD with symptoms of difficulty focusing.  The treatment note lists a new diagnosis of ADHD and a prescription for Adderall.  The note does not explain how the Veteran's symptoms meet the diagnostic criteria for ADHD.  In August 2023 a VA PTSD examination was provided.  The examiner diagnosed PTSD and unspecified depressive disorder.  The examination report identifies the Veteran's symptomatology, medical history, and level of impairment.   In a separate opinion,, the examiner explained that ADHD was not diagnosed because the Veteran's attention, concentration, and executive functioning difficulties were onset in adulthood and these symptoms were associated with her PTSD and unspecified depressive disorder diagnoses.  In November 2024, an additional VA PTSD examination was provided.  The examiner diagnosed PTSD and MDD.  The examination report also identifies the Veteran's symptomatology, medical history, and level of impairment.  In a separate opinion, the examiner explained that the Veteran's symptoms of inattention and lack of concentration did not meet the diagnostic criteria for ADHD under the DSM-5 because the symptoms started after a traumatic incident (military sexual trauma) which occurred during the Veteran's active military service.  He also explained the attention and concentration symptoms were evaluated as symptoms of PTSD
 was not diagnosed because the Veteran's attention, concentration, and executive functioning difficulties were onset in adulthood and these symptoms were associated with her PTSD and unspecified depressive disorder diagnoses.  In November 2024, an additional VA PTSD examination was provided.  The examiner diagnosed PTSD and MDD.  The examination report also identifies the Veteran's symptomatology, medical history, and level of impairment.  In a separate opinion, the examiner explained that the Veteran's symptoms of inattention and lack of concentration did not meet the diagnostic criteria for ADHD under the DSM-5 because the symptoms started after a traumatic incident (military sexual trauma) which occurred during the Veteran's active military service.  He also explained the attention and concentration symptoms were evaluated as symptoms of PTSD and MDD.

Here, the evidence confirms the Veteran has symptoms of inattention and difficulty with concentration.  However, the evidence weighs against a finding that she has a diagnosis of ADHD which is separate and distinct from her service-connected PTSD with MDD disability.  While a VA clinician listed an ADHD diagnosis prior to prescribing a medication, the VA treatment record does not include a complete diagnostic evaluation.  The August 2023 and November 2024 VA examiners performed complete diagnostic evaluations, explained why ADHD was not diagnosed, and specifically attributed the Veteran's attention and concentration symptoms to her service connected PTSD and MDD diagnoses.  Accordingly, the weight of the evidence supports a finding that ADHD is not a separately diagnosed psychiatric disorder.  In addition, the Veteran's attention and concentration symptoms are considered and compensated through the service-connected psychiatric disability rating.  Thus, separate disability ratings for anxiety would constitute impermissible pyramiding.  38 C.F.R. § 4.14.

Accordingly, the claim for entitlement to service connection for ADHD, rated as a disability separate and distinct from the Veteran's service-connected PTSD with MDD, is denied.  See 38 C.F.R. §§ 4.14, 4.130, General Rating Formula for Mental Disorders; Esteban v. Brown, 6 Vet. App. 259, 262 (1994).

REASONS FOR REMAND

1. Service connection for a hysterectomy is remanded.

Under the provisions of the AMA, the Board must remand any appeal that cannot be granted in full for correction of a pre-decisional duty-to-assist error.  38 C.F.R. § 20.802(a).  

The duty to assist requires VA to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with military service, and the record does not contain sufficient information to make a decision on the claim.  38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006).

VA has a duty to ensure any medical examination or opinion it provides is adequate.  Barr v. Nicholson, 2 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)).  A VA medical examination or opinion is adequate "where it is based upon consideration of the veteran's prior medical history and examinations."  Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007).

The Veteran seeks entitlement to service connection for a hysterectomy.  The April 2024 rating decision on appeal includes favorable findings that the Veteran underwent surgery for a hysterectomy in April 2023, she participated in in-service TERAs (toxic risk exposure activities), and service connection is established for PTSD.  The Board additionally notes an April 2020 VA PTSD examination confirmed a diagnosis of PTSD is supported by a MST (military sexual trauma) stressor which was substantiated by markers related to the Veteran's conduct around the event.  

In April 2023, the Veteran asserted she underwent a hysterectomy in April 2023 due to menorrhagia (heavy or prolonged menstrual bleeding) and fibroids which were developed after she was raped during her active service.  The MST is confirmed and the Veteran is competent to report heavy or prolonged menstrual bleeding.  Prior to the April 2024 rating decision on appeal, the AOJ did not obtain an opinion as to whether the hysterectomy was directly related to the MST or to in-service symptoms of menorrhagia.  In October 2023, the AOJ obtained an opinion addressing secondary service connection.  In this opinion, a VA examiner stated the Veteran's hysterectomy was less likely than not proximately due to her PTSD.
2023, the Veteran asserted she underwent a hysterectomy in April 2023 due to menorrhagia (heavy or prolonged menstrual bleeding) and fibroids which were developed after she was raped during her active service.  The MST is confirmed and the Veteran is competent to report heavy or prolonged menstrual bleeding.  Prior to the April 2024 rating decision on appeal, the AOJ did not obtain an opinion as to whether the hysterectomy was directly related to the MST or to in-service symptoms of menorrhagia.  In October 2023, the AOJ obtained an opinion addressing secondary service connection.  In this opinion, a VA examiner stated the Veteran's hysterectomy was less likely than not proximately due to her PTSD.  However, the opinion did not address whether the hysterectomy (or the need for a hysterectomy) was aggravated by her PTSD.  As this opinion did not address both causation and aggravation it is inadequate to evaluate secondary service connection.  See Stefl, supra; see also El-Amin v. Shinseki, 26 Vet. App. 136 (2013); Allen v. Brown, 7 Vet. App. 439 (1995) (holding a secondary service connection must address both causation and aggravation to be deemed adequate).  The failure to obtain adequate etiology opinions prior to the April 2024 rating decision is a pre-decisional duty to assist error.

The matters are REMANDED for the following action:

Provide the claims file to an appropriate clinician.  After review of the entire file, the clinician is asked to opine as to whether the Veteran's hysterectomy is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) related to an in-service event, including an MST or in-service menorrhagia symptoms.  

In addition, the clinician is asked to opine as to whether the Veteran's hysterectomy is least as likely as not likelihood is at least approximately balanced or nearly equal, if not higher) (a) caused by; or (b) aggravated by her service connected psychiatric disorder (PTSD with MDD).  

In providing these opinions, the clinician must fully discuss the nature of the Veteran's hysterectomy and PTSD with MDD disabilities and the current medical understanding of any causal or aggravating relationship between these disabilities.  

The opinion provided must explicitly address both causation and aggravation to be deemed adequate, acknowledging these are separate inquiries that require different rationales.  In this context, the examiner must be advised aggravation means any increase in disability, i.e., additional functional impairment, resulting from the secondarily claimed condition due to the primary disability.  There is no requirement that such increase be permanent in nature.  An opinion that simply states there is no anatomical or biological connection between the conditions without addressing whether there is additional functional impairment will be deemed insufficient to facilitate an informed decision on the Veteran's claim.

For the purposes of these opinions, the clinician should assume the Veteran's statements about her symptoms are credible, unless they are inconsistent with the medical evidence or with medical principles concerning his condition.  The Board emphasizes that this does not constitute a positive credibility determination, as the Board will weigh the evidence if the appeal returns.

If there is a medical basis to support or doubt the history provided by the Veteran, the clinician should provide a fully reasoned explanation.  In doing so, the clinician may identify any discrepancies, inconsistencies, or contradictions contained in the evidence of record, and may state whether or not the Veteran's lay statements are supported by medical or other evidence.  The clinician may not dismiss the Veteran's statements about her symptoms solely because they are not documented in contemporaneous treatment records.

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?

All findings must be reported in detail and all opinions must be accompanied by a clear rationale.  If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided.

If the clinician determines an additional examination is needed to provide the requested opinion, schedule an examination.

 

 

M. HYLAND

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Jeanne Celtnieks

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.