Citation Nr: 0007253 Decision Date: 03/17/00 Archive Date: 03/23/00 DOCKET NO. 96-19 750 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for urinary dysfunction. REPRESENTATION Appellant represented by: Virginia Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD J.M. Daley, Associate Counsel INTRODUCTION The veteran had active duty for training from April 16, 1991 to July 26, 1991, and active service in the United States Army from May 11, 1994 to February 14, 1995. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 1995 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), located in Roanoke, Virginia. REMAND When the veteran was given an Army enlistment examination in March 1993, he denied specified urinary symptoms (which did not include urine retention) and no relevant diagnoses were noted. On May17, 1994, about six days after entering active service, he complained of back pain for two days. He was noted to have a history of a back injury five months earlier when he was in a motor vehicle accident. Other records refer to another motor vehicle accident shortly before he entered service. A report of orthopedic consultation dated in June 1994 indicates that the veteran "stated he was hospitalized [in] Jan 94 for inability to urinate," with 600 cc obtained by catheterization. He reported that doctors had told him his prostate was abnormal. Later in June, he complained of urinary incontinence. In August 1994, the veteran was seen at the urology clinic of Blanchfield Army Hospital. He reported a voiding dysfunction since February 1994, manifested by hesitancy, frequency, modest decrease in fullness of stream and nocturia. The veteran again stated that he had been catheterized at the civilian hospital and that 600cc had been obtained. He was also noted to have injured his back in a motor vehicle accident in April 1994 (prior to active service). Following examination, the impression was bladder neck dysfunction, which might or might not be associated with the back injury versus urethral stricture. Service medical records reflect that in early October the veteran was hospitalized for complaints of pelvic pressure and pain, and an inability to urinate since the prior evening. The assessment was rule out urothrosis versus prostatism and doubt prostatitis. Associated clinical entry sheets show a diagnosis of bladder neck obstruction with retention. The diagnosis after several days' treatment was voiding dysfunction. A report dated in mid-October recites a "lifelong history of voiding dysfunction which has been worse in the past month." That report notes a similar episode in February 1994, for which the veteran had been treated at a civilian hospital. The impression was unspecified void dysfunction, rule out stricture. The report notes that such could represent a variant of Hinman's syndrome or the non-neurogenic bladder. The veteran underwent cystoscopy and renal and bladder ultrasound, which were unremarkable. He also underwent psychiatric evaluation, which resulted in no diagnosis of a mental disorder. A service medical report dated in November 1994 shows a diagnosis of paruresis, probably mostly psychogenic in nature. Other records dated in November note the veteran's history of back injury, without obvious neurologic deficit. The veteran was transferred to Walter Reed Army Medical Center. An air evacuation summary shows admission to Walter Reed and treatment by Dr. Zorn from November 19 to November 29, 1994. That report notes a six-month history of voiding difficulty, which reportedly began when the veteran developed lower back pain after initiation of physical therapy after admission to the Army. The report also notes a single episode of urinary retention, approximately 18 months prior to service, which was stated to be self-resolving. The admitting diagnosis was voiding dysfunction and the discharge diagnosis was Type II external sphincter dyssynergy. Although a psychiatric consultation was to be conducted, no report is in the file. The veteran was transferred back to his duty station with instructions to self catheterize on a per needed basis. A late December 1994 note indicates that, per a conversation between Dr. Foley and Walter Reed physicians, no major illness was present. Dr. Foley referred to the bladder disorder as external bladder dyssynergy. He noted that it was an "EPTS condition" and that the veteran would be offered a Chapter 16 separation from service and given a separation physical. The veteran was given a physical examination in December 1994 for separation. All body systems were noted to be normal. He was noted to have a normal prostate, normal sphincter tone, and bulbocavernous reflux. It was noted that he had had a normal neurological examination at Water Reed and at another Army hospital. The veteran received a discharge under honorable conditions for misconduct that involved various infractions including making false official statements. See February 3, 1995 memorandum to the veteran from Commander, Company B, 3d Bn, 187th Infantry Regiment. Documentation in the claims file reflects that the veteran's service records were sent to the Army Board for Correction of Military Records and that the RO requested clinical and hospitalization records from Blanchfield Army Hospital and Walter Reed Army Medical Center. The RO also requested the veteran to identify treatment at a private hospital in January or February 1994 and to provide a release for such records. The veteran failed to report for two scheduled VA examinations. In support of his claim for service connection he has testified and submitted written argument denying any urinary problems before service and catheterization at a civilian hospital. The veteran's representative stated that the complete Walter Reed records were not associated with the claims file and would be probative of the service connection issue. Prior to determining the well groundedness of the appellant's claim, VA should ensure that adequate attempts are made to associate the veteran's complete service medical records with the claims file. See 38 U.S.C.A. § 5103 (West 1991); Ivey v. Derwinski, 2 Vet. App. 320 (1992); Murincsak v. Derwinski, 2 Vet. App. 363 (1992); see also Hayre v. West, 188 F.3d 1327 (Fed. Cir. 1999). Accordingly, this claim is returned to the RO for the following: 1. The RO should make another attempt to secure the complete clinical records associated with the veteran's hospitalization and evaluation at Walter Reed Army Medical Center from November to December 1994. The records should include any report of psychiatric evaluation. The RO should request such from all appropriate official sources, to include the Army Board for Correction of Military Records. The RO's attempt should be documented in the claims file, along with any responses, negative or positive. 2. Despite the veteran's allegations in support of his claim that he had no urinary dysfunction prior to service, the service medical records contain information that was obtained from him to the contrary, specifically indicating that he was treated at a civilian hospital in January and/or February 1994 for urinary retention, that he was catheterized and that 600 ccs of urine were obtained. The RO is to requested to ask the veteran to identify the civilian hospital at which he was treated in early 1994 for urinary problems and to authorize the release of his medical records, thereby giving him another opportunity to cooperate. He should also be asked to identify all medical treatment or evaluation for his urinary problems since separation from service and authorize the release of his medical records, to include records of any psychiatric treatment or evaluation, inasmuch as there are indications that his urinary condition is psychogenic. The RO should obtain any evidence identified that is not currently in the file. 3. Thereafter, if additional evidence is received, the RO should determine whether the veteran's claim is well grounded. If the RO determines that the claim is well grounded it should obtain any indicated medical examination/opinion by a board certified urologist and psychiatrist, if the latter is deemed appropriate, as to the correct diagnosis and etiology of any current urinary dysfunction and its relationship, if any, to the urinary problems in service and to the pre- service history as noted in the service medical records and/or any additional medical evidence received. The claims file and a separate copy of this complete remand must be made available to the examiner(s), who must review the claims file. 4. The RO should then review the record and re-adjudicate the issue on appeal. If the benefit sought on appeal remains denied the veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The veteran has the right to submit additional evidence and argument on the matter the Board has remanded to the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). Thereafter, the case should be returned to the Board, if in order. The Board intimates no opinion as to the ultimate outcome of this case. The veteran need take no action unless otherwise notified. This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44- 8.45 and 38.02-38.03. JANE E. SHARP Member, Board of Veterans' Appeals