Citation Nr: 0001195 Decision Date: 01/13/00 Archive Date: 01/27/00 DOCKET NO. 95-11 422 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to service connection for a postoperative left hydrocele as secondary to the service connected postoperative left inguinal hernia with ilio-inguinal nerve entrapment. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Trueba-Sessing, Associate Counsel INTRODUCTION This appeal arises from an October 1994 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin, which denied the benefits sought on appeal. The veteran, who had active service from December 1968 to September 1970, appealed that decision to the Board of Veterans' Appeals (BVA or Board). At present, after REMAND to the RO for additional development, the veteran's case is once again before the Board for appellate review. FINDING OF FACT The postoperative left hydrocele is not show not be causally or etiologically related to the service connected postoperative left inguinal hernia with ilio-inguinal nerve entrapment, or that it is otherwise related to his period of service. CONCLUSION OF LAW The veteran's postoperative left hydrocele is not proximately due or the result of a service connected disease or injury. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.102, 3.303, 3.310 (1999). REASONS AND BASES FOR FINDING AND CONCLUSION As a preliminary matter, the Board finds that the veteran's claim is "well-grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). See Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). That is, the Board finds that the veteran has presented a claim which is not implausible when his contentions and the evidence of record are viewed in the light most favorable to the claim. The Board is also satisfied that all relevant facts have been properly and sufficiently developed. Accordingly, no further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a) (West 1991). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a) (1999). Furthermore, if a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. See 38 C.F.R. § 3.303(b) (1999). In addition, disabilities which are found to be proximately due to or the result of a service connected disease or injury shall be service connected. See 38 C.F.R. § 3.310 (1999). In this case, the veteran was awarded service connection and a noncompensable disability evaluation for a postoperative left inguinal hernia in a January 1971 rating decision. Subsequently, this award was recharacterized in a February 1995 rating decision to a 10 percent disability evaluation for a postoperative left inguinal hernia with ilio-inguinal nerve entrapment. At present, the veteran contends he is entitled to service connection for a postoperative left hydrocele as it is related to his service connected postoperative left inguinal hernia with ilio-inguinal nerve entrapment. With respect to the service medical records, the service records indicate that, in August 1970, a left inguinal hernioplasty was performed on the veteran. During such hernioplasty, a small direct inguinal hernia was found; however, the veteran's postoperative course was without complications. As to the post-service medical evidence, the evidence indicates that, in January 1994, Richard P. Reigel, M.D., performed a left hydrocelectomy on the veteran, as reflected by the medical records from the Saint Michael's Hospital dated January 1994. An April 1994 letter by Dr. Reigel, further indicates he began treating the veteran in 1991 for his left hydrocele, which historically had been occurring on the same side as where the previous in-service inguinal hernia repair was performed. In this regard, Dr. Reigel indicates that it was extremely likely that the veteran's hydrocele formed as a consequence of the previous hernia repair. In a March 1994 letter by a VA physician, the physician indicates that the veteran's 1970 left inguinal herniorrhaphy involved an operation on the gastrointestinal system, but that his January 1994 hydrocelectomy of the left testicle involved the genital urinary system. As such, the physician concluded that, given that these procedures involved two different body systems and were twenty-four years apart from each other, there was no etiological basis for the conclusion that the hydrocele resulted from the hernia operation. A May 1994 VA examination report indicates the veteran had a history of hydrocele, recurrent surgeries and possible epididymitis treated with antibiotics with intermittent improvement. The examination report further indicates the veteran was in pain, and that such pain might be secondary to his past left inguinal hernia repair, with some possible nerve entrapment with scar tissue. Medical records from the William S. Middleton VA Hospital dated in October 1994 indicate the veteran was treated for pain in the left groin. At that time, EMG and nerve conduction studies were performed on the veteran revealing no electrodiagnostic evidence of radiculopathy, plexopathy or neuropathy; the results were within normal limits bilaterally. In addition, bilateral hip x-rays were obtained which revealed normal joint spaces and no lytic lesions. Furthermore, the records indicate the examiner felt that the veteran's left groin pain was probably the result of ilioinguinal nerve entrapment which was secondary to trauma the veteran incurred during his left inguinal herniorrhaphy. In a March 1995 letter by Dr. Reigel, he indicates that it was certainly possible that the veteran's hydrocele and his left inguinal hernia repair were related; however, no one could say with certainty. In addition, he indicates that hydroceles occurring after inguinal hernia repair were not uncommon, and such hydroceles were generally believed to result from obstructions of lymphatic vessels along the spermatic cord at the time of the surgical correction of the inguinal hernia. Subsequently, in December 1995, Dr. Reigel examined the veteran for left spermatocele, and performed surgery on the veteran in order to correct this anomaly. However, the examination and surgery reports issued subsequent to this surgery do not discuss the etiology of the veteran's spermatocele. A July 1996 VA expert opinion by an Associate Professor of Urology and Chief Physician for Urology indicates that, while any scrotal surgery has the potential for altering the venous and lymphatic blood supply from the testes, the temporal separation of over twenty years between the veteran's left inguinal herniorrhaphy and the development of the hydrocele essentially precludes any cause or relationship. The VA expert further notes that the development of the spermatocele was not the result of the previous hydrocelectomy, and, after a detail explanation of the medical reasons for his conclusion, the examiner indicated that their etiology was completely different and separate, and one should not lead to the other. In an October 1996 letter by Dr. Reigel, he indicates that he had been treating the veteran since 1991 for his a left hydrocele, and again reiterated his belief that it was more likely than not that the veteran's hydrocele was related to his previous left inguinal hernia. An April 1997 VA examination report indicates the veteran suffered from chronic left epididymal or testicular pain, with no evidence of active infection, inflammatory or neoplastic process, or impotence. In addition, the examination report indicates that, while it was very possible that the hydrocele may have been the result of the veteran's previous hernia surgery, he was unable to make such determination with the available data; however, given the veteran's history, it was unlikely that the hydrocele was the result of the surgery which was performed many years prior to the hydrocele's clinical presence. Finally, the examination report indicates the veteran presented evidence of spermatocele, which was probably not related to the veteran's prior hydrocele surgery. Statements dated in September 1997 and January 1998, with an April 1999 addendum, signed by Dr. Harry Etter from the Whitefish VA Medical Center, and by Dr. Michael Agee from the Helena VA Medical Center, respectively, indicate it was likely that the veteran's hydrocele and spermatocele were associated with his previous hernia condition. Medical records from the William S. Middleton VA Hospital for the period including March 1995 to April 1997, records from the Fort Harrison VA Medical Center (VAMC) dated from October 1996 to February 1998, and the Whitefish VAMC dated from April 1997 to November 1998 indicate the veteran was examined and treated, among other health problems, for left hydroceles. A March 1998 VA expert opinion by the Chief Physician for Surgical Services indicates that, after reviewing the veteran's medical records in great detail, it was the expert's opinion that the left hydrocele which developed approximately in 1991 was not the result of the left inguinal hernia repair in 1970. The expert further noted that there is known evidence of hydrocele following inguinal surgery, but that the percentage of occurrence was only 7 percent; however, as the veteran's initial surgery was done 21 years prior to the onset of the hydrocele, it was very unlikely that they were in any way related, as the incident of hydrocele following inguinal surgery was usually in the early postoperative period. The examiner also noted that it was impossible to say unequivocally that there could not be some relationship, but in the expert's opinion that was extremely unlikely. Finally, the record includes various statements, made in correspondence and during the January 1996 appeal hearing, by the veteran and his representative tending to link the veteran's postoperative left hydrocele to his service connected postoperative left inguinal hernia with ilio- inguinal nerve entrapment and/or to his service. With respect to the evidence, the law is clear that it is the Board's duty to assess the credibility and probative value of the evidence and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). In weighing the evidence available, the Board acknowledges that the various opinions contained in the October 1994 records from the William S. Middleton VA Hospital, and the various statements by Dr. Reigel, Dr. Etter and Dr. Agee link the veteran's postoperative left hydrocele to his service connected postoperative left inguinal hernia with ilio-inguinal nerve entrapment. However, the Board finds that this medical evidence is outweighed by the evidence contained in March 1994 statement from the VA physician, the April 1997 VA examination report, and the July 1996 and March 1998 VA expert opinion reports discussed above. In this respect, the Board finds that the medical opinions contained in the October 1994 records from the William S. Middleton VA Hospital, and the statements by Dr. Reigel, Dr. Etter and Dr. Agee primarily contain conclusions without providing any specific objective medical reasons as to how these physicians arrived at their medical findings/conclusions. As such, this medical evidence is unpersuasive. On the other hand, there is evidence showing at least a 20- year gap between the veteran's in-service hernioplasty and his hydrocelectomy in the early-mid 1990s. In addition, the March 1994 statement from the VA physician, the April 1997 VA examination report, and the July 1996 and March 1998 VA expert opinion reports show these health care providers had the benefit of a review of all pertinent medical records in great detail, and discussed the rational upon which they based their conclusions, including the finding that the veteran's postoperative left hydrocele was not related to his service connected postoperative left inguinal hernia with ilio-inguinal nerve entrapment. Therefore, after a review of the record, the Board finds that the veteran has not submitted persuasive medical evidence showing that his postoperative left hydrocele is proximately due to his service connected postoperative left inguinal hernia with ilio-inguinal nerve entrapment, or that it is otherwise related to his period of service. As the preponderance of the evidence is against the veteran's claim of entitlement to service connection for a postoperative left hydrocele as secondary to the service connected postoperative left inguinal hernia with ilio-inguinal nerve entrapment, his claim must be denied. See 38 U.S.C.A. § 5107(a). In arriving at this determination, the Board has considered the various statements by the veteran, and his representative. However, as these individuals are lay persons not competent to offer an opinion requiring medical knowledge, such statements do not constitute medical evidence which would prove the existence of a service-related disability. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995); Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1995). The Board has considered 38 U.S.C.A. § 5107(b). Section 5107(b) expressly provides that the benefit of the doubt rule must be applied to a claim when the evidence submitted in support of the claim is in relative equipoise. The evidence is in relative equipoise when there is an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. When the evidence is in relative equipoise, the reasonable doubt rule must be applied to the claim, and thus, the claim must be resolved in favor of the claimant. See Massey v. Brown, 7 Vet. App. 204, 206-207 (1994); Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). In this case, after reviewing the evidence of record, the Board finds that the evidence is not in relative equipoise, and thus, the benefit of the doubt rule is not for application in this case. ORDER Service connection for a postoperative left hydrocele as secondary to the service connected postoperative left inguinal hernia with ilio-inguinal nerve entrapment is denied. RAYMOND F. FERNER Acting Member, Board of Veterans' Appeals