Citation Nr: 0305205 Decision Date: 03/20/03 Archive Date: 04/03/03 DOCKET NO. 00-14 501A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to service connection for sexual impotence. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R.P. Harris, Counsel INTRODUCTION The appellant had active service from November 1942 to August 1943. This matter came before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Pittsburgh, Pennsylvania, Regional Office (RO), which denied service connection for sexual impotence. Parenthetically, in written statements dated in 2002, appellant cancelled personal hearings that had previously been requested. In December 2002, the Board referred the case to the Veterans Health Administration (VHA) of the VA for a medical opinion regarding the service connection issue in controversy, pursuant to 38 U.S.C.A. § 7109 (West 2002) and 38 C.F.R. § 20.901 (2002). In January 2003, a VHA medical opinion was rendered, and the Board subsequently provided appellant's representative a copy thereof. Thereafter, his representative submitted an informal hearing presentation. The case is now ready for appellate review. FINDING OF FACT It is at least as likely as not that appellant's erectile dysfunction is related to the service-connected psychophysiological gastrointestinal reaction with impaired sphincter or medications taken for the service-connected disability. CONCLUSION OF LAW With resolution of reasonable doubt in the appellant's favor, sexual impotence is proximately due to or the result of a service-connected psychophysiological gastrointestinal reaction with impaired sphincter or medications taken for the service-connected disability. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.310(a) (2002). REASONS AND BASES FOR FINDING AND CONCLUSION In light of the Board's allowance herein of appellant's service connection claim at issue, the evidence of record is adequate. In pertinent part, service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). By a 1944 rating decision, service connection was granted for gastritis and spastic colitis. Subsequently, in 1958, the service-connected disability was rated as psychophysiological gastrointestinal reaction. By a June 1996 rating decision, the service-connected disability was rated as psychophysiological gastrointestinal reaction with impaired sphincter. Appellant argues that he has had longstanding impotence caused by the service-connected psychophysiological gastrointestinal reaction with impaired sphincter. It is asserted that he has "performance anxiety" and nerve damage resulting from the impaired anal sphincter that affects penile nerves and erectile functioning. Additionally, it is contended that medications taken for the service-connected psychophysiological gastrointestinal reaction with impaired sphincter also causes his impotence. Neither the service medical records nor post-service clinical records proximate to service include any complaints, findings, or diagnoses pertaining to impotence. The service medical records indicated that appellant had children and VA clinical records dated in the 1960's indicated that he had four children from his current second marriage. VA clinical records reflect that he had other health problems, including a low back disability, obesity, diabetes, and hypertensive disease, prior to an October 1995 VA psychiatric examination. On October 1995 VA psychiatric examination, appellant reported that his diarrhea and associated symptoms had ruined his life; and stated that he had stopped sleeping with his wife 25 years ago and had been impotent ever since. It appears that this was the initial allegation of impotence in the evidentiary record. He also stated that it had been explained to him that his anal sphincter had been severely impaired from nerve damage caused by diarrhea. In 1997, an ultrasound of the aorta was interpreted as consistent with atherosclerotic disease. Later in 1997, VA clinical records indicated that a vacuum erection device was applied and appellant did achieve full erection. A physician's assistant's assessment was arterial insufficiency and venous incompetence. On May 1998 VA urologic examination, a history of impotence for the past 30 years was reported. It was noted that although appellant had achieved a good erection during prior clinic treatment with an erection device, this was without an ejaculatory process. The assessment was "[o]rganic impotence, probably secondary to ischemic peripheral vascular disease." In a subsequent July 1999 written statement, a private urologist referred to appellant's history of rectal sphincter dysfunction, erectile dysfunction, and diarrhea with rectal incontinence; and stated that he had discussed with appellant that "there is a definite relationship with the rectum, the bladder, and the urinary dysfunction." In an October 1999 clinical record, that private urologist stated that appellant "wanted me to comment how the nerves to the rectal sphincter and urinary tract are closely tied. Hopefully, we can just take care of that with this dictation." Certain medical articles regarding the etiology of impotence have also been submitted by appellant and are of record. In view of the somewhat confusing clinical evidence then of record regarding the etiology of appellant's erectile dysfunction, the Board requested a VHA medical opinion; and a VHA medical opinion by a urologist was rendered in January 2003 in response to questions from the Board. In that January 2003 VHA medical opinion, the urologist stated that the entire claims folder had been reviewed; that appellant's medical history included numerous disabilities, among which were chronic gastritis, colitis, psychophysiological gastrointestinal reaction, chronic perineal pain, and chronic diarrhea; that numerous medications had been prescribed, including for perineal pain; and that appellant had received treatment for erectile dysfunction. In response to the Board's question "[i]s it as likely as not (as distinguished from mere possibility) that appellant has impotence that is causally or etiologically related to, or aggravated by, the service- connected psychophysiological gastrointestinal reaction with impaired sphincter or medications taken for the service- connected disability?", the VHA medical opinion stated, in pertinent part: Chronic diarrhea as a consequence of the chronic colitis can cause a lax anal sphincter. The pudendal nerve has both motor and sensory functions. The bulbocavernosus reflex is elicited by squeezing the glans and observing for contraction of the anal sphincter. This reflex is mediated through the pudendal nerve and illustrates the intimate neurologic connection between the anal sphincter and penile sensation. The pudendal nerve also enables erection. A private [u]rologist examined [appellant] in 1999 [and] a lax sphincter was noted.... The literature associates chronic gastrointestinal dysfunction with psychological consequences that include sexual dysfunction. Pain, diarrhea, fecal incontinence all reduce self-image, can cause depression and result in psychogenic erectile dysfunction.... The medications used to manage [appellant's] gastrointestinal and other medical conditions...are all associated with sexual dysfunction.... It is my opinion that these numerous medications contribute to his erectile dysfunction.... It is my opinion that the GI disease with impaired sphincter function is related to the erectile dysfunction. The ED [erectile dysfunction] at this time is multifactorial and is caused by organic, psychological and pharmacological causes. The Board assigns significant evidentiary weight to the VHA medical opinion by a urologist. Although the VHA medical opinion described the etiology of appellant's erectile dysfunction as multifactorial, nevertheless the erectile dysfunction was also characterized as related to the service- connected psychophysiological gastrointestinal reaction with impaired sphincter or medications taken for the service- connected disability. As the United States Court of Appeals for Veterans Claims (Court) has stated in Smith v. Derwinski, 1 Vet. App. 235, 237 (1991), "[d]etermination of credibility is a function for the BVA." After weighing all of the evidence, it is the Board's conclusion that the positive evidence outweighs any negative evidence with respect to the secondary service connection appellate issue. Based on this evidence, and with resolution of doubt in the appellant's favor, it appears that secondary service connection for sexual impotence is warranted. ORDER Secondary service connection for sexual impotence is granted. ____________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.