VOIDING DYSFUNCTION

M. TENNER · 2026 · Case ID: A26039823

MIXED

Summary

The veteran, who served in the Marine Corps from March 1969 to December 1970, appeals the denial of an increased rating for prostate cancer residuals and the denial of service connection for bowel perforation, ulcerative colitis, obstructive sleep apnea, and TDIU. The Board reviewed the case under the Appeals Modernization Act, considering evidence of record up to the November 2025 AOJ decision. The veteran's prostate cancer residuals were rated at 40% for voiding dysfunction, which the Board found to be the predominant residual, and this rating was not increased as the evidence did not support a higher evaluation. The Board found the VA examination adequate for this specific issue. However, the claims for service connection for bowel perforation, ulcerative colitis, obstructive sleep apnea, and TDIU were remanded. The Board noted that the VA examinations for these remanded conditions were inadequate as they failed to provide opinions on the nexus between the claimed conditions and service-connected PTSD or prostate cancer residuals, or to address the PACT Act implications for sleep apnea related to Camp Lejeune exposure. The case was remanded for new VA examinations to address these nexus issues and for adjudication of the TDIU claim.

Rationale

Evidence weighs against rating in excess of 40%; VA examination documented voiding dysfunction requiring 2-4 changes daily; No evidence of voiding dysfunction requiring appliance or >4 changes daily

Service Branch

MARINE CORPS

Special Benefit

TDIU

Docket No.

251104-592091

Full Decision Text

Citation Nr: A26039823
Decision Date: 04/28/26 Archive Date: 04/28/26

DOCKET NO. 251104-592091
DATE: April 28, 2026

ORDER

From December 21, 2023, a rating in excess of 40 percent for prostate cancer residuals is denied.

REMANDED

Service connection for bowel perforation, to include as secondary to prostate cancer residuals, is remanded.

Service connection for ulcerative colitis, to include as secondary to posttraumatic stress disorder, is remanded.

Service connection for obstructive sleep apnea, to include as secondary to posttraumatic stress disorder, is remanded.

A total disability rating based on individual unemployability is remanded.

FINDING OF FACT

1. From December 21, 2023, the Veteran's prostate cancer residuals manifested in voiding dysfunction requiring absorbent materials which required changing 2-4 times per day, but not requiring the use of an appliance or absorbent materials which required changing more than four times per day.

CONCLUSION OF LAW

1. From December 21, 2023, the criteria for a rating in excess of 40 percent for prostate cancer residuals have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.20, 4.21, 4.115a, 4.115b, Diagnostic Code 7528, 7542.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the Marine Corps from March 1969 to December 1970.

This appeal is being adjudicated according to the appellate process set forth under the Appeals Modernization Act (AMA). See 84 Fed. Reg. 138, 169 (Jan. 18, 2019); 38 C.F.R. § 19.2.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated April 2025, June 2025, and November 2025 issued by a Regional Office of the United States Department of Veterans Affairs (VA).

In the November 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.

Therefore, the Board may only consider the evidence of record at the time of the April 2025, June 2025, and November 2025 agency of original jurisdiction (AOJ) decisions on appeal, as well as any evidence submitted by the Veteran [or representative] with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 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[s], 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 claims of service connection for bowel perforation, service connection for ulcerative colitis, service connection for obstructive sleep apnea, and entitlement to a TDIU, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Evidentiary Standards

In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits.

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). It follows, that when the evidence persuasively favors one side or the other, the benefit-of
will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Evidentiary Standards

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). It follows, that when the evidence persuasively favors one side or the other, the benefit-of-the-doubt rule is not applied. Lynch v. McDonough, 21 F.4th, 776 (Fed. Cir. 2021).

The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on what this evidence shows, or fails to show, on the claim.

Any findings favorable to the Veteran made by the VA Regional Office in notification of a decision are binding on the Board unless rebutted by evidence that identifies a clear and unmistakable error in the favorable finding. 38 C.F.R. §?20.810(a). "Findings" means "conclusions on questions of fact and application of law to facts made by an adjudicator concerning the issue under review." Id.

Increased Ratings

Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3.

In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that the rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. Westi, 13 Vet. App. 31, 34 (1999).

1. From December 21, 2023, a rating in excess of 40 percent for prostate cancer residuals is denied.

From December 21, 2023, the Veteran's prostate cancer residuals are rated under 38 C.F.R. § 4.115a diagnostic code (DC) 7528, which governs malignant neoplasms of the genitourinary system (i.e., prostate cancer). A Note following DC 7528 explains that following the cessation of surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedures, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of section 3.105(e) of the chapter. If there has been no local reoccurrence or metastasis, the disability is to be rated on its residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4
7528, which governs malignant neoplasms of the genitourinary system (i.e., prostate cancer). A Note following DC 7528 explains that following the cessation of surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedures, the rating of 100 percent shall continue with a mandatory VA examination at the expiration of six months. Any change in evaluation based upon that or any subsequent examination shall be subject to the provisions of section 3.105(e) of the chapter. If there has been no local reoccurrence or metastasis, the disability is to be rated on its residuals as voiding dysfunction or renal dysfunction, whichever is predominant. 38 C.F.R. § 4.115b, Diagnostic Code 7528.

Voiding dysfunction is rated under 38 C.F.R. § 4.115a DC 7542, which provides:

Rating (%)

Voiding dysfunction:

Rate particular condition as urine leakage, frequency, or obstructed voiding

Continual Urine Leakage, Post-Surgical Urinary Diversion, Urinary Incontinence, or Stress Incontinence:

Requiring the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day 60

Requiring the wearing of absorbent materials which must be changed 2 to 4 times per day 40

Requiring the wearing of absorbent materials which must be changed less than 2 times per day 20

Urinary frequency:

Daytime voiding interval less than one hour, or; awakening to void five or more times per night 40

Daytime voiding interval between one and two hours, or; awakening to void three to four times per night 20

Daytime voiding interval between two and three hours, or; awakening to void two times per night 10

Obstructed voiding:

Urinary retention requiring intermittent or continuous catheterization 30

Marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following:

1. Post void residuals greater than 150 cc.

2. Uroflowmetry; markedly diminished peak flow rate (less than 10 cc/sec).

3. Recurrent urinary tract infections secondary to obstruction.

4. Stricture disease requiring periodic dilatation every 2 to 3 months 10

Obstructive symptomatology with or without stricture disease requiring dilatation 1 to 2 times per year 0

On careful review, the evidence weighs persuasively against finding that from December 21, 2023, the Veteran's prostate cancer residuals warranted a rating in excess of 40 percent.

The Veteran was afforded a VA examination assessing male reproductive organ conditions (including prostate cancer) in December 2024. The VA examiner documented review of the Veteran's VA e-folder in combination with an in-person examination. The VA examiner documented the Veteran's report that his prostate cancer onset in 2016 when he was treated with radiation androgen deprivation therapy with Zoladex, which was then discontinued. He has been in remission and in watchful waiting status since completing radiation therapy in April 2017. He reported symptoms of bladder and bowel incontinence as well as erectile dysfunction. He had an ostomy for rectal incontinence. There was no renal dysfunction. The Veteran had dysfunction with urine leakage that required absorbent materials which must be changed 2-4 times per day, but did not require the use of an appliance. He had increased urinary frequency with daytime intervals between 1-2 hours and nighttime awakening to void five or more times. There were no signs or symptoms of obstructed voiding. The Veteran did not have a history of chronic prostatitis, urethritis, epididymitis, orchitis, or urinary tract infections. The Veteran did not have additional residuals or complications of prostate cancer. The VA examiner opined that there was no change in the Veteran's prostate cancer and no additional diagnoses were rendered. Although the VA examiner marked the Veteran's prostate cancer as active, in a March 2025 Addendum to the opinion they clarified that the Veteran's prostate cancer is in remission and that there is no evidence to support the prostate cancer being active.

While VA treatment records throughout the appeal period document that the Veteran is followed for prostate cancer residuals, they do not contain additional information regarding their severity.

The Board notes that there is no local reoccurrence or metastasis, and it is thus appropriate to rate the disability on residuals as voiding dysfunction or renal dysfunction, whichever is predominant. See December 2024 VA examination. Thus, a 100 percent rating under DC 7528 is not for application. Also, there is no renal dysfunction, nor is there recurrent urinary tract infection. Id. Thus, the condition is rated based on voiding dysfunction. The Veteran had voiding dysfunction requiring the wearing of absorbent material which must be changed 2-4 times per day and did not require the use of an appliance. He had increased urinary frequency with daytime intervals of 1-2 hours and nighttime awakening five or more times per night. There is no evidence of record showing that the Veteran's voiding dysfunction requires the use of an appliance or the changing of absorbent materials more than four times per day.

Accordingly, from December 21, 2023, a rating in excess of 40 percent for prostate cancer residuals must be denied.

REASONS FOR REMAND

Service connection for bowel perforation requiring total colectomy and end-ileostomy is remanded.

In December 2024, the Veteran filed a claim for an increased rating for prostate cancer residuals for bowel incontinence. The Regional Office characterized and developed the Veteran's claim as one for service connection for bowel perforation requiring total colectomy and end ileostomy of sphincter control (bowel perforation) to include as secondary to prostate cancer, to include as related to exposure to contaminated water at Camp Lejeune, and to include under 38 U.S.C. § 1151.

The Veteran was afforded VA examinations regarding the nature and likely etiology of his bowel perforation disability in September 2025; however, no examiner to date has provided an opinion regarding whether the Veteran's currently diagnosed bowel perforation disability was at least as likely as not proximately due to or the result of, or aggravated by his prostate cancer residual disability. Accordingly, remand is warranted for additional VA examination.

Service connection for obstructive sleep apnea is remanded.

Service connection for ulcerative colitis is remanded.

The Board addresses the issues of service connection for obstructive sleep apnea and service connection for ulcerative colitis together. Their factual and legal analyses substantially overlap and their dispositions are the same.

The Veteran seeks service connection for obstructive sleep apnea and ulcerative colitis disabilities that he asserts are related to service-connected PTSD. In

Secondary service connection contemplates two theories, namely that a service-connected disability either causes the secondary disability or that it makes the secondary disability worse, e.g., aggravation.

The Veteran was afforded a VA examination in June 2015; however, the examiners failed to render an opinion regarding whether the Veteran's currently diagnosed obstructive sleep apnea and ulcerative colitis disabilities were aggravated by his service-connected PTSD. El-Amin v. Shinseki, 26 Vet. App. 136, 138-40 (2013) (a medical opinion regarding secondary service connection must address both causation and aggravation to be adequate). For the foregoing reasons, the Board finds that the June 2015 VA examinations are inadequate for the purposes of adjudicating the Veteran's claims. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) ("[O]nce the Secretary undertakes the effort to provide an examination when developing a service-connection claim, . . . he must provide an adequate one.").

Additionally, with respect to the claim for service connection for obstructive sleep apnea, the evidence of record shows that the Veteran participated in a toxic exposure risk activity (TERA), specifically exposure to contaminated water at Camp Lejeune during active service. Under the Sergeant Fist Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), VA is required to provide a disability examination and medical nexus opinion when the Veteran submits a compensation claim and has evidence of a disability, and participation in a TERA, but the evidence is not sufficient to establish service connection for the disability. See 38 U.S.C. § 1168(a).

A total disability rating based on individual unemployability (TDIU) is remanded.

Because the determination of the claims for service connection
evidence of record shows that the Veteran participated in a toxic exposure risk activity (TERA), specifically exposure to contaminated water at Camp Lejeune during active service. Under the Sergeant Fist Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), VA is required to provide a disability examination and medical nexus opinion when the Veteran submits a compensation claim and has evidence of a disability, and participation in a TERA, but the evidence is not sufficient to establish service connection for the disability. See 38 U.S.C. § 1168(a).

A total disability rating based on individual unemployability (TDIU) is remanded.

Because the determination of the claims for service connection for bowel perforation, service connection for ulcerative colitis, and service connection for obstructive sleep apnea could significantly impact a decision on whether the Veteran is entitled to a TDIU, the issues are inextricably intertwined. A remand on the claim is required.

The matters are REMANDED for the following action:

1. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed bowel perforation disability.

2. Schedule the Veteran for a VA examination to determine the nature and etiology of the claimed obstructive sleep apnea disability.

3. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's ulcerative colitis disability.

The examiners should provide an opinion as to the following:

Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's currently diagnosed bowel perforation disability was aggravated by his service-connected prostate cancer residual disability. The examiner is advised that "aggravation" means any increase in severity of the underlying disability beyond its natural progression. NOTE: Proximate cause is not required. It is sufficient if the Veteran's prostate cancer disability was a contributing factor to the aggravation of his bowel perforation disability.

Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's currently diagnosed obstructive sleep apnea disability was caused by his service-connected PTSD. It is sufficient if the Veteran's PTSD was a contributing factor to the obstructive sleep apnea Why do you say so?

Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's currently diagnosed obstructive sleep apnea was aggravated by his service-connected PTSD. The examiner is advised that "aggravation" means any increase in severity of the underlying disability beyond its natural progression. NOTE: Proximate cause is not required. It is sufficient if the Veteran's PTSD was a contributing factor to the aggravation of his obstructive sleep apnea.

Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's obstructive sleep apnea is related in any way to exposure to toxins due to his participation in a TERA. When providing this opinion, the examiner must consider the total potential synergistic combined effect of all toxic exposure risk activities of the Veteran.

Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's currently diagnosed ulcerative colitis disability was caused by his service-connected PTSD. It is sufficient if the Veteran's PTSD was a contributing factor to the ulcerative colitis. Why do you say so?

Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's currently diagnosed ulcerative colitis was aggravated by his service-connected PTSD. The examiner is advised that "aggravation" means any increase in severity of the underlying disability beyond its natural progression. NOTE: Proximate cause is not required. It is sufficient if the Veteran's PTSD was a contributing factor to the aggravation of his ulcerative colitis.

The examiners are reminded to consider the Veteran's lay statements regarding the nature and onset of his disabilities, including any evidence concerning continuity of symptomatology, as he is legally permitted to report his symptoms, past medical history, and experiences.

The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or
ative colitis was aggravated by his service-connected PTSD. The examiner is advised that "aggravation" means any increase in severity of the underlying disability beyond its natural progression. NOTE: Proximate cause is not required. It is sufficient if the Veteran's PTSD was a contributing factor to the aggravation of his ulcerative colitis.

The examiner must not opine on the credibility of the Veteran. The examiner may, however, discuss whether there is any medical reason to accept or reject the Veteran's assertions.

A clear and detailed rationale for the opinions, including a discussion of the facts and medical principles involved should be provided as it will be of considerable assistance to the Board. Please do not simply list the facts on which you relied.

The examiner is informed that reliance on a lack of treatment and/or gap between discharge from military service and diagnosis of a disability, without explaining why such evidence is significant, may be an insufficient rationale.

If the examiner relies on medical treatises, the examiner should identify and discuss the treatises.

If the examiner determines that a disability was acute rather than chronic, the examiner should explain how he or she arrived at that conclusion rather than providing a conclusory opinion. For example, what would the examiner expect to see if a condition was chronic, how do the Veteran's lay statements, if any, affect the conclusion?

If the examiner determines that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or examiner (i.e., additional facts are required or the examiner does not have the needed knowledge or training). The examiner should review the record prior to the examination and elicit from the Veteran a detailed medical history.

4. Thereafter, adjudicate the claim for a TDIU.

M. Tenner

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Lee, P. M., Associate Counsel

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.

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