BVA9503162 DOCKET NO. 90-51 668 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES Whether new and material evidence has been submitted to reopen a claim for service connection for a gastrointestinal disorder. Entitlement to secondary service connection for a gastrointestinal disorder. Entitlement to service connection for chronic impotence. Entitlement to an increased evaluation for prostatitis, currently rated 20 percent disabling. Entitlement to an increased (compensable) evaluation for urethritis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Richard V. Chamberlain, Counsel INTRODUCTION The veteran served on active duty from June 1942 to October 1945. A September 1982 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas, denied service connection for atrophic gastritis and spastic colon with post-operative diverticular disease of the colon. The veteran was notified of this decision in October 1982, and he did not appeal. In 1989, the veteran, in part, submitted an application to reopen a claim for service connection for a gastrointestinal disorder. This appeal arises from RO rating decisions that denied the veteran's application to reopen a claim for service connection for a spastic colon, denied secondary service connection for a gastrointestinal disorder, denied service connection for chronic impotence, denied a rating in excess of 20 percent for prostatitis, and denied an increased (compensable) evaluation for urethritis. The Board of Veterans' Appeals (Board) remanded the case to the RO in March 1991 and April 1992 for additional development. The case was returned to the Board in August 1994. In a statement in support of his claim dated in June 1993 the veteran claimed he had developed anxiety and a nervous condition caused by constant problems with his prostate condition. This issue is not before the Board and is referred to the RO for appropriate action. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he has a chronic gastrointestinal disorder that began in active service or is due to prolonged intake of broad-spectrum antibiotics for his service-connected prostatitis and urethritis. He alleges that he has submitted new and material evidence to reopen a claim for service connection for a gastrointestinal disorder, and he requests service connection for a gastrointestinal disorder based on incurrence in service or a secondary basis. He maintains that he is impotent due to removal of his left testis or his service-connected genitourinary disorder, and he requests service connection for chronic impotence. He asserts that he has frequent prostate infections and urinary problems due to his service-connected prostatitis, and he requests a higher rating for this disorder. Additionally, he maintains that his urethritis is more severe than currently rated, and he requests a compensable evaluation for this disorder. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims files. Based on its review of the relevant evidence, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the claims for an increased evaluation for prostatitis and an increased (compensable) rating for urethritis. It is also the decision of the Board that there is no new and material evidence to reopen a claim for service connection for a gastrointestinal disorder, and that the veteran has not submitted evidence of well-grounded claims for secondary service connection for a gastrointestinal disorder and for service connection for chronic impotence. FINDINGS OF FACT 1. Service connection is in effect for prostatitis, rated 20 percent; left orchiectomy (excision of a testicle, Dorland's Illustrated Medical Dictionary 1095 (25th ed. 1974)), rated 10 percent; synovitis of the left knee, rated 10 percent; malaria, rated zero percent; and urethritis, rated zero percent. The combined rating for the service-connected disabilities is 40 percent, and the veteran is entitled to special monthly compensation on account of anatomical loss of a creative organ (removal of left testis). 2. An unappealed September 1982 RO rating decision denied service connection for atrophic gastritis and spastic colon with post-operative diverticular disease of the colon. 3. Evidence submitted since the September 1982 RO rating decision and considered in conjunction with the 1989 application to reopen a claim for service connection for a gastrointestinal disorder is cumulative in nature, and, when viewed in the context of the earlier evidence of record, does not raise a reasonable possibility of a change in the prior adverse decision. 4. The veteran's claims for secondary service connection for a gastrointestinal disorder and service connection for chronic impotence are not supported by competent medical evidence tending to show a link between these conditions and any service-connected disability, or by any evidence of impotence prior to 1990. 5. The veteran's prostate disorder is manifested primarily by decreased caliber of the urine stream, diurnal frequency 8 to 9 times, nocturia once, and complaints of inability to control urination, dribbling, and pain; urination at intervals of one hour or less or the wearing of absorbent material due to voiding dysfunction that must be changed 2 to 4 times per day is not found. 6. The veteran's urethritis is asymptomatic and any symptoms associated with stricture of the urethra have been considered in the evaluation of the prostate disorder. CONCLUSIONS OF LAW 1. The additional evidence received subsequent to the final RO rating decision of September 1982, denying service connection for atrophic gastritis and spastic colon with post-operative diverticular disease of the colon, is not new and material; the claim is not reopened; and the prior RO rating decision remains final. 38 U.S.C.A. §§ 5108, 7105 (West 1991); 38 C.F.R. § 3.156 (1993). 2. The veteran's claims for secondary service connection for a gastrointestinal disorder and for service connection for chronic impotence are not well-grounded. 38 U.S.C.A. § 5107 (West 1991). 3. The criteria for a rating in excess of 20 percent for prostatitis are not met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321, 4.7, 4.20, 4.115, Part 4, Codes 7512, 7526, 7527. 4. The criteria for a compensable rating for urethritis are not met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321, 4.7, 4.115, Part 4, Code 7518 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran served on active duty from June 1942 to October 1945. A service document shows that he served in campaigns in North Africa and Europe during World War II. The service medical records show that the veteran underwent medical examination for induction into service in June 1942. At that time, no significant disabilities were found. In February 1943, he was seen for gastroenteritis. In December 1944, he was hospitalized for treatment of an acute episode of food poisoning. The diagnosis was acute gastroenteritis, cause undetermined. From March 31 to April 4, 1945, he was hospitalized for treatment of acute enteritis, catarrhal, cause undetermined. The report of his medical examination for discharge from service in October 1945 shows no gastrointestinal complaints. Clinical evaluation showed a normal abdominal wall and viscera. The service medical records also show that the veteran was treated for prostatitis and urethritis. These records do not indicate the presence of impotence. Service connection is currently in effect for prostatitis, rated 20 percent; orchiectomy (left testis), rated 10 percent; synovitis of the left knee, rated 10 percent; malaria, rated zero percent; and urethritis, rated zero percent. The combined rating for the service-connected disabilities is 40 percent, and he is entitled to special monthly compensation for anatomical loss of a creative organ. VA, service department and private medical reports show that the veteran was treated and underwent various examinations in the late 1940's, 1950's, 1960's and 1970's. A private medical report shows that the veteran was seen in September 1946 for various complaints, including abdominal pains, associated with malaria. A report of VA medical examination in December 1946 shows that the veteran had a palpable liver beneath the right costal margin. There were tenderness in the right lower quadrant and a tender mass contiguous with the liver edge in the right flank. Jaundice was present. It was noted that he had had malaria for the past three years and that his last attack was in July 1945, and that he often had cramping pains throughout his abdomen. A service department summary of the veteran's hospitalization from December 1946 to January 1947 shows that he was hospitalized for complaints associated with malaria. During this hospitalization, in January 1947, he underwent a barium enema that showed a marked redundancy of the ascending colon. The entire bowel was visualized. There was no pathology demonstrated. The impression was normal barium enema. An organic disease was not found during this hospitalization. The veteran underwent VA examination in March 1947. A gastrointestinal series indicated that the duodenal cap was constantly ragged. No definite ulcer was seen. Duodenitis was suspected. The descending colon was slightly spastic. He complained of generalized abdominal tenderness, most marked on the left. No digestive system diagnosis was recorded. The veteran underwent a VA examination in April 1948. He complained of stomach upset and reported that he had pains in the stomach much of the time. His abdomen was soft and flat. A service department report shows that the veteran was hospitalized from October to December 1948. The admitting diagnosis was epididymitis, acute, nonvenereal, right testicle. A barium enema during this hospitalization in October 1948 revealed a negative colon and terminal ileum. The discharge diagnosis was epididymitis, acute, nonvenereal, right testicle. The veteran underwent VA examination in January 1951. He complained of cramps in his stomach. Examination of his digestive system showed no abnormalities. A private medical report shows that the veteran underwent a VA fee-basis special genitourinary examination in April 1951. The diagnoses were seminal vesiculitis, chronic, severe; left epididymitis; and urethral stricture. The veteran underwent a special VA genitourinary examination in June 1954. The diagnoses were no prostatitis found; and no urethral stricture. A service department letter, dated in February 1952, notes that the veteran received treatment on various dates from November 1946 to December 1951 for gastrointestinal disturbances. A summary of VA hospitalization from February to March 1955 shows that the veteran received psychiatric treatment. The diagnosis was anxiety reaction, chronic, moderately severe, manifested by numerous somatic complaints, history of occasional skin rashes, and tremulousness and feeling of sexual inadequacy, and masculine inadequacy. Two statements from fellow servicemen, dated in May 1955, are to the effect that the veteran had gastrointestinal problems while in service. A private medical report, dated in June 1955, shows that the veteran was seen in 1953 for psychiatric problems. The clinical impression was anxiety state (mild) with irritable bowel syndrome. Another private medical report, dated in June 1955, shows that the veteran was seen in 1954 and 1955. The diagnoses were anxiety neurosis; possible schizophrenia; and gastritis, irritable intestinal tract. A service department summary of the veteran's hospitalization from September to December 1958 shows that he underwent removal of his left testis and epididymis during this hospitalization. The diagnosis was acute, left epididymitis, E. coli No. 6140. The veteran underwent VA examination in January 1960. His complaints included stomach trouble. His digestive system was normal. A gastrointestinal disorder was not found. He also underwent a special genitourinary examination. The diagnoses were surgical absence of the left testicle and epididymis; and history of chronic prostatitis. There were no complaints of impotence. A report from M. Grossman, M.D., dated in December 1964, shows that the veteran had a history of stomach discomfort since 1943. He had various gastrointestinal complaints, including bloating, pain in his stomach when empty, and abdominal cramping. Clinical evaluation showed abdominal tenderness. It was noted that he had anacidity by two gastric analyses and a spastic colon by proctoscopy and barium enema. The diagnoses were spastic colon, severe, chronic; and atrophic gastritis, moderate, chronic. The veteran underwent VA examination in December 1965. He had various abdominal complaints and underwent a special gastrointestinal examination. No abnormalities were found on examination. The assessments were atrophic gastritis, not found; and spastic colon, not found. An upper gastrointestinal series showed no abnormalities at this examination. The veteran also underwent a special VA genitourinary examination. There were no complaints concerning impotence. The diagnosis was chronic prostatitis, history of, no evidence of activity at the time of examination. A report from Maurice S. Grossman, M.D., dated in February 1966, notes that the veteran had been receiving treatment since 1958. It was reported that he had various disorders, including atrophic gastritis (achlorhydria), secondary to Addison's disease; hypometabolism secondary to Addison's disease; and hypovitaminosis. It was noted that he was treated for these disorders with various medications, including cortisone and intermittent antibiotics for intercurrent infections. The veteran underwent VA examination in April 1966. At a special VA gastrointestinal examination, he complained of pain in his stomach, gas and nausea, and abdominal cramps with diarrhea. An upper gastrointestinal series showed no abnormalities. His abdomen was normal on inspection. On percussion, there was normal sonority. On auscultation, there was normal peristalsis. On palpation, there was tenderness on epigastrium and right lower quadrant. There was no rigidity or distress. No masses were felt. The diagnosis was atrophic gastritis, not found. At a special genitourinary examination, the veteran gave a history of prostatitis that came on about four times a year requiring prostatic massage and medication. He complained of pain in his perineum. He felt that his gland was sore. The diagnoses were chronic prostatitis, mild to moderate; and surgical absence of the left testicle. There were no complaints of impotence. In June 1967, the Board, in part, denied service connection for a stomach disorder. Private medical reports show that the veteran was treated for gastrointestinal problems in 1972. A report of barium studies by C. K. Jenkins, M.D., dated in October 1972, notes the presence of diverticulosis associated with acute sigmoid diverticulitis, the inflammatory segment extending over most of the sigmoid colon and involving a long segment; and an otherwise negative barium enema. Reports from Truman Frank Appel, M.D., dated in 1972, show that the veteran was seen for hemorrhoids, Grade II to III, internal and external with prolapse; multiple perianal comedos; cryptitis; and that he had a normal proctosigmoidoscopy. These reports also show that he was treated for epigastric distress with Cantil with Phenobarbital and diet; and Vibramycin. A summary of VA hospitalization in April 1979 shows that the veteran underwent visual internal urethrotomy for urethral stricture disease. A decision of the Board in April 1980 allowed an increased rating for prostatitis from 10 to 20 percent. VA and private medical reports show that the veteran was treated for various disorders, including gastrointestinal and genitourinary problems, in the 1980's. VA records indicate that the veteran was treated primarily for non-service-connected disabilities in the 1980's. A report of barium enema study by Dr. Jenkins, dated in August 1981, shows moderately advanced diverticulosis of the colon, but without evidence of diverticulitis; and an otherwise negative study. These reports also show that the veteran was treated by Dr. Appel in 1981 and 1982 for gastrointestinal problems with medication and diet. A private medical report of hospitalization in January 1982 shows that the veteran underwent fiber-optic colonoscopy, complete, with biopsy and fulguration of sigmoid colon polyp. The diagnoses were diverticular disease of the colon with moderate sigmoid inflammation; and sessile sigmoid colon polyp, probably benign adenoma, pathology report pending. A subsequent note in Dr. Appel's records shows that the pathology report was "benign". Service connection for a gastrointestinal disability was denied in September 1982 as described. The veteran was notified the following month. No notice of disagreement was received within a year of that notice. The veteran testified at a hearing at the RO in December 1985. His testimony was to the effect that he had gastrointestinal problems since service. A statement from the veteran's wife, dated in May 1986, is to the effect that she had known the veteran since December 1948 and that he had had continuous stomach problems since that time. Duplicate copies of service medical records and of the service department letter dated in February 1952 were received in 1986. Reports from Pedro P. Torres, M.D., show that the veteran was treated for gastrointestinal problems in 1986 and 1988. In November 1988, the veteran underwent complete colonoscopy with biopsies of mucosal sigmoid colon at a private hospital. The postoperative diagnosis was diverticulosis was diverticulosis and colon polyps. A report from Dr. Torres, dated in December 1988, notes that the veteran made good recovery following the colonoscopy with biopsy, and that the biopsy report revealed no evidence of malignancy. Private medical reports show that the veteran was seen by Ray G. Hooper, M.D., for genitourinary problems from 1986 to 1989. Reports of this treatment indicate that pus was occasionally found in his urine, and that he occasionally complained of perineal discomfort, and tenderness of the prostate. A report from Dr. Hooper, dated in November 1988, notes that the veteran had been recently seen with the complaint of perineal discomfort and apparent tenderness in the region of the bulbous urethra. Urinalysis was within normal limits. His prostate was one plus, soft and benign. However, he complained of extreme tenderness in both lobes on palpation, and he was placed on medication in November 1988. Dilation showed a rather long anterior urethral stricture and panendoscopy was performed. At that time, a urinalysis was within normal limits. Panendoscopy showed a rather long, severe anterior urethral stricture extending from the midline to within approximately 1.5 centimeters of the membranous urethra. The prostatic urethra was completely obstructed with lateral lobes which met in the midline and median lobe enlargement. The bladder showed Grade I to early II trabeculation. No cellules, diverticula, stones or tumors were noted. A CT (computed tomography) of the abdomen and pelvis in June 1989 was essentially negative. A report from Dr. Torres, dated in July 1989, notes that the veteran had been treated since December 1986 for complaints of frequent episodes of short-lasting, shooting rectal pain, lasting from a few seconds to a few minutes, and aggravated by straining with constipation. It was noted that the pain was present at night and at times, would awaken the patient. In addition, he had a previous history of diverticulosis and chronic diverticulitis, as well as colon polyps. It was noted that he had undergone a thorough evaluation of his colon and rectal symptoms with findings of a small polyp in the sigmoid colon, as well as extensive diverticulosis, more dense in the area of his sigmoid colon as well. Following the evaluation, the colon problems were treated with increasing bulk in his diet and medication. It was noted that the veteran had been last seen in November 1988 and found to be in satisfactory condition. The veteran underwent a VA urology examination in September 1989. His complaints included constant pain in the colon, inability to hold urination, urine dribbles, and frequent stomach disorders. The veteran reported that he was recommended for prostate surgery based on recent findings found by Dr. Hooper, which he refused. He stated that he had a clear urethral discharge daily. He reported occasional dysuria with perineal discomfort just prior to, as well as during, urination. He reported diurnal frequency of 8 to 9 times and nocturia once. He reported urgency, reduction of urinary stream force, occasional hesitancy, and post void dribbling. Micturition was witnessed by the examiner, and there appeared to be hesitancy. The urinary stream force appeared reduced and evacuation of the bladder appeared prolonged. The veteran denied hematuria, urolithiasis, and venereal disease. He had no urinary incontinence at night time, but stated that during the day, whenever he stood up, there was a "constant drip." He stated that he did not have an erection as often as he used to, that the erection was not of the same quality as before, and that the erection could not be maintained for the same length of time. He reported intercourse with his wife once or twice monthly and that he reached orgasm and ejaculation, but stated that the ejaculation caused perineal discomfort. Surgical examination revealed a normally nourished, normally developed veteran with no costovertebral angle tenderness, organomegaly or tenderness, but with distention of the urinary bladder 3 inches above the pubis. After the examination the veteran emptied his bladder. There was a right subcostal cholecystectomy scar which was well-healed. Bowel sounds were normal and no bruit was heard. Femoral arterial pulsations were strong and equal and without bruits. There was no inguinal lymphadenopathy present. The phallus appeared circumcised. The external urethral meatus was larger than normal and there was no urethral discharge present. The left testicle, epididymis and vas were absent and there was a vertical left scrotal scar. The right testicle, epididymis and vas were normal. No groin hernia was present. The prostate was one plus enlarged, but otherwise normal. The prostate did not appear to be abnormally tender. The diagnoses after performance of blood and urine tests were prostatitis by history, no evidence at the time of examination; left orchiectomy; urethritis by history with no evidence at the time of examination; impotence not found; urethral stricture confirmed by cystoscopy in November 1988; and benign prostatic hyperplasia. The record shows that the veteran was seen by Dr. Hooper for genitourinary problems on various dates from 1990 to 1992. The reports received from Dr. Hooper indicate that the veteran was seen for various genitourinary complaints, including perineal discomfort and urgency type incontinence. His prostate was occasionally swollen and tender, and he was treated with medication and hot sitz baths. In May 1990, he was recommended for a serum testosterone test because he reported he had not had an erection in six weeks. A report of his treatment in July 1990 notes that his testosterone was 4.3 (2.7-10.7), which was considered normal. The veteran continued to complain of difficulty with erections and he was referred to Dr. McNichol. In October 1990, Dr. McNichol referred the veteran for Prolactin, testosterone, and snap-gauge evaluation. The testosterone was 603, the Prolactin was 5.3, and the snap gauge showed the blue element only was broken, and that the others were intact. While the veteran complained of pain that occurred in front of the rectum up through the scrotum, Dr. McNichol could not relate this pain to his problem with erections. He was recommended for further evaluation, but none of the records indicate that the veteran was found to be impotent. The reports from Dr. Hooper show that the veteran continued to complain of perineal and rectal discomfort and was treated with tetracycline. A report received from Dr. Hooper shows that a biopsy of a segment of the prostate was performed in October 1990. The diagnosis was prostate, needle biopsy, benign prostatic tissue. Another report received from Dr. Hooper shows that a CT of the pelvis with contrast was performed in September 1991. The diagnosis was prominent prostate, otherwise unremarkable CT scan. VA medical reports show that the veteran was treated for various disorders and underwent examinations from 1990 to 1993. These reports show that he was treated with medications for various disorders. The various medications included penicillin and Tetracycline. These reports show treatment for various genitourinary and gastrointestinal problems, including urinary tract infection that was treated with medication. The veteran underwent VA genitourinary examination in July 1992. He gave a history of a urethral stricture treated with a visual internal urethrotomy in 1979 and that he had had no follow-up studies since that time. He reported treatment for recurrent prostatitis by Dr. Hooper, and stated that he currently had a decrease in the caliber of the urinary stream. He also gave a history of left orchiectomy in 1958. His abdomen was flat and relaxed with no palpable masses or areas of tenderness. The kidneys were not palpably enlarged. The right testis was normal in size, shape and consistency. The left testis was surgically absent. There was no inguinal hernia. The prostate was small and benign. The diagnosis was urethral stricture with postoperative visual urethrotomy. He was recommended for a urology consultation. A report of VA urology consultation in August 1992 notes that the veteran had complaints of voiding symptoms, hesitancy, decreased urinary stream force, nocturia and terminal dribbling. He complained of occasional incontinence. Urinalysis showed no abnormalities. The assessment was symptoms of bladder outlet obstruction secondary to recurrent stricture diagnosis versus BPH (benign prostatic hypertrophy). He was recommended for cystoscopy or retrograde urogram as soon as possible. A retrograde urogram showed diffuse narrowing of the urethra with no definite area of stricture. Post void film showed moderate prostatic impression and small post voiding residual. The impression was diffusely narrow urethra. A VA upper gastrointestinal series in September 1992 showed persistence of small hiatal hernia with moderate degree of gastroesophageal reflux. The marked edema seen on the previous examination, which was consistent with antral gastritis and duodenitis, had improved markedly. The examiner did not see any evidence of crater on this examination. II. Legal Analysis The veteran's claims are well-grounded, except where otherwise noted, meaning they are plausible. The Board finds that all relevant evidence has been obtained with regard to these claims and that no further assistance to the veteran is required to comply with VA's duty to assist him. 38 U.S.C.A. § 5107(a) (West 1991). A. Whether New and Material Evidence has been Submitted to Reopen a Claim for Service Connection for a Gastrointestinal Disorder In order to establish service connection for a disability, the evidence must show the presence of it and that it resulted from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or diagnoses including the word "chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The September 1982 RO rating decision denying service connection for a gastrointestinal disorder is final with the exception that the veteran may later reopen his claim if new and material evidence is submitted. 38 U.S.C.A. §§ 5108, 7105. The question now presented is whether new and material evidence has been submitted since the September 1982 RO decision to permit reopening the claim for service connection for a gastrointestinal disorder. Manio v. Derwinski, 1 Vet.App. 140 (1991). For evidence to be deemed new, it must not be cumulative or redundant; to be material it must be relevant and probative to the issues at hand and, when viewed in the context of all the evidence, it must raise a reasonable possibility of a change in the prior adverse outcome. 38 C.F.R. § 3.156(a); Colvin v. Derwinski, 1 Vet.App. 171 (1991). The evidence of record at the time of the September 1982 RO rating decision that denied service connection for atrophic gastritis and spastic colon with post-operative diverticular disease of the colon consisted of statements from the veteran and service comrades that he had gastrointestinal problems that began in service; service medical records; and VA, service department, and private medical records. The evidence showed that the veteran was treated for acute gastrointestinal disorders in service and shortly after service, but did not demonstrate the presence of chronic gastrointestinal disorders until many years after service and did not relate any chronic gastrointestinal disorder found after service to a gastrointestinal condition treated in service or to any other incident of service. Since the September 1982 RO rating decision the veteran testified at a hearing in 1985 to the effect that he had gastrointestinal problems in service, and a statement from his wife dated in 1986 was received to the effect that the veteran had gastrointestinal problems since 1948. This evidence is similar to statements from the veteran and service comrades of record in 1982 and is not considered new. Additional VA, service department, and private medical records were also received that were duplicate copies of evidence already of record, or showed that the veteran continues to receive treatment for various gastrointestinal disorders, and are not considered new because they are cumulative of evidence of record in 1982. The documents received since the 1982 RO rating decision are only cumulative and redundant when compared with the evidence of record at the time, and when viewed in the context of all the evidence raise no reasonable possibility of a change in the prior adverse decision. The additional evidence is not considered new and material. Morton v. Principi, 3 Vet.App. 508 (1992). As no new and material evidence has been submitted since the September 1982 RO rating decision no further analysis of the application is required. The claim for service connection for a gastrointestinal disorder is not reopened, and the earlier 1982 RO rating decision remains final. Kehoskie v. Derwinski, 2 Vet.App. 31 (1991). B. Secondary Service Connection a Gastrointestinal Disorder and Service Connection for Chronic Impotence Secondary 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). The threshold question to be answered with regard to the claims for secondary service connection for a gastrointestinal disorder and for service connection for chronic impotence is whether the veteran has presented evidence of well-grounded claims; that is, claims that are plausible. 38 U.S.C.A. § 5107(a). If he has not presented well-grounded claims, his appeal must fail and there is no duty to assist him further in the development of the claims. Murphy v. Derwinski, 1 Vet.App. 78 (1990). The evidence reveals that the veteran has various gastrointestinal disorders, including spastic colon, atrophic gastritis, and diverticulosis, but none of the medical evidence links any chronic gastrointestinal disorder to a service- connected disability or to the prolonged use of medication to treat a service-connected genitourinary disorder. The veteran's statements that he has a gastrointestinal disorder due to the prolonged use of medication to treat his service-connected genitourinary disorders cannot be used to medically link his current gastrointestinal problems to a service-connected disability because he is a layman who does not have the competence to make conclusions as to medical causation. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). In regard to the matter of service connection for chronic impotence, the service records do not show the presence of chronic impotence, and the post-service records do not indicate the presence of possible impotence until around 1990, many years later. At a VA urology examination in September 1989, the veteran reported having intercourse with his wife once or twice monthly and that he reached orgasm and ejaculation. I recognize that private medical reports of his treatment in 1990 reveal that he has problems with erections, but a report of his treatment in October 1990 notes that a physician didn't think his problems with erections were related to symptoms of his genitourinary disorder(s). The veteran asserts that he is impotent due to removal of his left testis in 1958, but he has submitted no evidence showing that any impotence is causally related to the removal of his left testis. When the determinative issue involves medical causation, competent medical evidence must be submitted to show a plausible or well-grounded claim. Grottveit v. Brown, 5 Vet.App. 91 (1993). To be well-grounded, a claim must be supported by evidence, not just allegations. Tirpak v. Derwinski, 2 Vet.App. 609 (1992). In this case, the veteran has submitted no medical evidence to link a gastrointestinal disorder to a service connected disorder or to treatment for such a disorder. Nor has he submitted any medical evidence to link any impotence to removal of his left testis in 1958 or to an incident of service. Thus, his claims for secondary service connection for a gastrointestinal disorder and for service connection for impotence are implausible and must be dismissed as not well-grounded. Grivois v. Brown, 6 Vet.App. 136 (1994). The RO is advised that decisions on the merits on the claims for secondary service connection for a gastrointestinal disorder and for service connection for impotence prior to and including this decision are to be regarded as dismissals, without finality as to the merits. Grottveit, 5 Vet.App. 91; Grivois, 6 Vet.App. 136. As finality on the merits does not attach, there can be no prejudice to the veteran in dismissing the claims, even though the RO decisions were on the merits. Bernard v. Brown, 4 Vet.App. 384 (1993). C. Increased Rating for Prostatitis In order to establish entitlement to a higher rating for a service-connected disability, the evidence must show symptoms of the disorder which meet or more nearly approximate the criteria for higher ratings under the applicable diagnostic codes in the Schedule for Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.7. The evidence shows that the veteran underwent visual internal urethrotomy in 1979 for urethral stricture disease. Under the circumstances, the veteran's prostatitis may be rated analogous to a transurethral resection of the prostate. 38 C.F.R. § 4.20. The residuals of prostate injuries, surgery, infections or hypertrophy may also be evaluated as chronic cystitis, in accordance with resulting functional disturbance of the bladder, under the provisions of 38 C.F.R. Part 4, Code 7512. 38 C.F.R. Part 4, Code 7527. Resection or removal of the prostate gland is evaluated as cystitis, in accordance with the severity of related symptoms, under the provisions of 38 C.F.R. Part 4, Code 7512. The minimum evaluation is 20 percent. 38 C.F.R. § 4.115a, Part 4, Code 7526. A 20 percent evaluation is warranted for moderately severe chronic cystitis with diurnal and nocturnal frequency with pain and tenesmus. A 40 percent evaluation requires severe cystitis with urination at intervals of one hour or less and a contracted bladder. 38 C.F.R. § 4.115a, Part 4, Code 7512. The provisions of 38 C.F.R. § 4.115a, Code 7512 and 7527 (Code 7526 was eliminated from the rating schedule) were redesignated and revised as § 4.115b and a new § 4.115a was added in 1994. 59 Fed. Reg. 2528 (Jan. 18, 1994). Prostate gland injuries, infections, hypertrophy, and postoperative residuals are now rated as voiding dysfunction or urinary tract infection, whichever is prominent. 38 C.F.R. § 4.115b, Code 7527. Voiding dysfunction is rated as leakage, frequency, or obstruction. A 20 percent evaluation is warranted for leakage that requires the wearing of absorbent materials which must be changed less than two times per day. A 40 percent evaluation is warranted for leakage that requires wearing of absorbent materials which must be changed 2 to 4 times per day. A 20 percent rating is warranted for urinary frequency, with the daytime voiding interval between one and two hours, or awakening to void three to four times per night. A 40 percent rating is warranted for daytime voiding interval less than one hour, or awakening to void five or more times per night. Obstructed voiding warrants a 30 percent rating when it requires intermittent or continuous catheterization. A 10 percent evaluation is warranted for urinary tract infections that require long-term drug therapy, 1 or 2 hospitalizations per year and/or requiring intermittent intensive management. A 30 percent evaluation is warranted for urinary tract infection with recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. 38 C.F.R. § 4.115a. When the regulations concerning entitlement to a higher rating are changed during the course of an appeal, the veteran is entitled to resolution of his claim under the criteria which is to his advantage. Karnas v. Derwinski, 1 Vet.App. 308 (1991). The veteran's voiding dysfunction is more prominent than his infections, which do not require drainage, frequent hospitalization, or continuous intensive management Private medical reports show that the veteran continues to be seen for various genitourinary problems, but these records do not indicate symptoms that cause more than moderately severe genitourinary impairment. At a VA urology examination in September 1989, he complained of inability to hold urination and urinary dribbling, and he was noted to have diurnal frequency of 8 to 9 times and nocturia once. Other evidence of record indicates that the veteran's prostatitis is, essentially, asymptomatic and that his service-connected genitourinary disorder is now manifested primarily by urethral stricture. The evidence does not indicate that this disorder causes urination at intervals of one hour or less in order to establish entitlement to a higher rating under the provisions of Diagnostic Code 7512 under the regulatory provisions in effect prior to the revision of the regulations in 1994, nor does the evidence indicate the presence of voiding dysfunction that requires the wearing of absorbent materials which must be changed 2 to 4 times per day or of a urinary tract infection requiring drainage/frequent hospitalizations or urinary tract infection requiring continuous intensive management to establish a higher rating under the criteria as revised in 1994. Nor does the evidence show that the veteran has urinary frequency at daytime intervals of less than one hour or that causes awakening to void five or more times per night to satisfy the criteria for a 40 percent rating under the new criteria based on urinary frequency. He does not require intermittent or continuous catheterization. Hence, the evidence does not show symptoms of the service-connected genitourinary disorder sufficient to warrant a higher schedular rating. Nor is an extraschedular rating appropriate for the service-connected prostatitis, as frequent hospitalization or marked interference with employment is not shown due to prostatitis. 38 C.F.R. § 3.321. The Board finds that the current 20 percent rating for the veteran's prostatitis best represents the veteran's disability picture and that the evidence is not in relative equipoise concerning the claim for a higher rating for this disorder. Hence, he is not entitled to favorable resolution of this claim based on reasonable doubt. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet.App. 49. The preponderance of the evidence is against the claim for a higher rating for prostatitis, and it must be denied. D. Increased (Compensable) Rating for Urethritis A zero percent evaluation is warranted for healed, slight to moderate stricture of the ureter requiring only occasional dilations (1 or 2 times a year). A 10 percent evaluation is appropriate when dilations are required every 2 or 3 months. 38 C.F.R. § 4.115a, Part 4, Code 7518. Under the above-noted changes to the regulatory provisions to 38 C.F.R. § 4.115a in January 1994, stricture of the urethra is rated as voiding dysfunction. A 20 percent evaluation may be assigned for voiding dysfunction that requires the wearing of absorbent material which must be changed less than two times per day. Thus, as with the issue of entitlement to a higher rating for prostatitis discussed above, the Board will consider the veteran's entitlement to an increased (compensable) rating for urethritis under the regulatory criteria in effect prior to 1994 and the criteria as revised in 1994. The overall evidence indicates that the veteran's service-connected genitourinary disorders are manifested primarily by urethral stricture and the manifestations of this disorder have been contemplated in the assignment of a 20 percent rating for prostatitis or urethral stricture as noted in the above discussion. These symptoms may not be reconsidered to support a separate compensable rating for urethritis, otherwise the same disability would be evaluated twice under different diagnoses. 38 C.F.R. § 4.14 (1993). The overall evidence indicates that the veteran's urethritis is found only by history, and the evidence shows no genitourinary symptoms that have not been considered in the assignment of the 20 percent rating for prostatitis to support a separate compensable rating for urethritis. Hence, the urethritis is considered asymptomatic. An extraschedular rating is not appropriate, as it does not cause frequent hospitalization or marked interference with employment. 38 C.F.R. § 3.321. The Board finds that the current zero percent rating for urethritis best represents the veteran's disability picture and that the preponderance of the evidence is against the claim for a compensable rating for this disorder. Since the preponderance of the evidence is against the claim, the evidence is not in relative equipoise and the veteran is not entitled to favorable resolution of his claim based on the doctrine of reasonable doubt. 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet.App. 49. ORDER The application to reopen a claim for service connection for a gastrointestinal disorder is denied. The claims for secondary service connection for a gastrointestinal disorder and for service connection for chronic impotence are dismissed as not well-grounded. An increased evaluation for prostatitis is denied. An increased (compensable) rating for urethritis is denied. J. E. DAY Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.