BVA9506405 DOCKET NO. 92-16 987 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE 1. Entitlement to service connection for impotency secondary to residuals of a gastrectomy and vagotomy. 2. Entitlement to an increased rating for residuals of a gastrectomy and vagotomy due to duodenal ulcer disease, evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Richard F. Williams, Counsel INTRODUCTION The veteran served on active duty from June 1948 to May 1955. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 1992 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which denied secondary service connection for impotency and a rating in excess of 20 percent for residuals of a gastrectomy and vagotomy due to duodenal ulcer disease. The case was remanded by the Board to the RO in October 1993. The purpose of that remand was met. In a decision entered in March 1994, the RO confirmed its earlier denial of secondary service connection for impotency. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that his impotency is etiologically related to the gastrectomy and vagotomy he underwent for his service-connected duodenal ulcer disease. He asserts, in essence, that the nerve network necessary for penile erectile function was severed by the surgery for his service-connected disability. He recalls that he was advised by a doctor just prior to the surgery that he would become impotent. He further claims that his service-connected residuals of a gastrectomy and vagotomy for duodenal ulcer disease are more disabling than currently evaluated. He states that the service-connected disability at issue is at least 40 percent disabling. In support of his claim, he states that he was hospitalized on four occasions in 1982 and currently weighs 164 pounds compared to his previous weight of 210 pounds. 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 file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the preponderance of the evidence is against the veteran's claims for secondary service connection for impotency and a rating in excess of 20 percent for residuals of a gastrectomy and vagotomy due to duodenal ulcer disease. FINDINGS OF FACT 1. An etiological relationship between impotency and a gastrectomy or vagotomy has not been demonstrated. 2. The service-connected status post gastrectomy is not manifested by episodes of epigastric disorders with characteristic circulatory symptoms, diarrhea, weight loss or other symptomatology compatible with more than mild functional impairment; his service-connected vagotomy is not manifested by alkaline gastritis or confirmed persistent diarrhea; he has a slightly decreased red blood cell count and hemoglobin and hematocrit levels, but no diagnosis of anemia secondary to peptic ulcer disease is apparent, and his duodenal ulcer disease is not productive of impairment of health manifested by weight loss or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year or other symptomatology consistent with more than moderately severe functional impairment. CONCLUSIONS OF LAW 1. Impotency is not proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (1994). 2. The criteria for a rating in excess of 20 percent for residuals of a gastrectomy with vagotomy for duodenal ulcer disease have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. §§ 3.321, 4.7, 4.111, 4.112, 4.114, Part 4, Codes 7305, 7308, 7348 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background The veteran served on active duty from June 1948 to May 1955. The enlistment examination shows he weighed 145 pounds. The service medical records show that the veteran was diagnosed with a duodenal ulcer. He was also treated for urethritis while on active duty. The service clinical records, including a report of a separation examination performed in May 1955, are negative for any finding indicative of impotency. On the separation examination he weighed 164 pounds. The veteran underwent several special VA examinations in March 1957, including gastrointestinal and general medical evaluations. His height and weight were recorded as 69 inches and 150 pounds, respectively, at that time. The genitourinary part of the general medical examination was reported as normal. Following gastrointestinal and upper gastrointestinal X-ray examinations, a diagnosis of duodenal deformity due to healed ulcer was recorded. An RO decision in May 1957 granted service connection and assigned a 10 percent rating for a duodenal ulcer. The veteran underwent a VA gastrointestinal examination in December 1971. His weight was recorded as 164 pounds at that time. The clinical impression was history of duodenal ulcer disease. An RO decision in January 1972 increased the rating for the veteran's service-connected duodenal ulcer disease from 10 percent to 20 percent. That rating has remained in effect ever since. Clinical records from the Brookwood Medical Center show that the veteran was hospitalized in February 1982 for evaluation of recurrent chest pain. His history included a myocardial infarction and peptic ulcer disease. Following clinical and diagnostic studies, the diagnoses were chest wall pain and gastric ulcer. The veteran was hospitalized at the same medical facility in August 1982 and underwent a hemigastrectomy and vagotomy for a gastric ulcer. The operative report is on file. No postoperative complications were noted. It was noted upon social history obtained from the veteran that he had two children. Additional clinical records from the Brookwood Medical Center show that the veteran was hospitalized in September 1982 for evaluation of three episodes of syncope after four episodes of diarrhea. The initial impression included post- gastrectomy with dumping syndrome. An atherosclerotic aneurysm was suspected upon pelvic angiography. A CT scan of the abdomen revealed dilatation of the proximal common iliac artery measuring 3 to 3.5 centimeters in diameter; it was opined that this represented an aneurysm of the right common iliac artery. The final diagnoses included syncope secondary to vasovagal episode and iliac aneurysm. The veteran was hospitalized at the same facility in October 1982 and underwent resection of the right iliac aneurysm and replacement of the distal aorta with bifurcation aortoiliac graft. No postoperative complications were noted. The veteran underwent a VA gastrointestinal examination in February 1992. He complained of gastrointestinal distress and impotence. He said that he had had a progressive decrease in erections and impotence since his gastrectomy with vagotomy and abdominal aneurysm repair with aortofemoral bypass. It was noted upon a review of systems that he had had occasional epigastric distress. He denied significant weight loss or diarrhea. Upon physical examination, it was noted that he was 5 feet 10 inches tall and weighed approximately 164 pounds. He appeared well developed and well nourished. A well-healed midabdominal scar was noted with a midabdominal hernia. No other pertinent physical findings were reported. An upper gastrointestinal X-ray series revealed a status post Billroth II with satisfactory postoperative appearance. Transient gastroesophageal reflux into the distal one-third of the esophagus was noted, which cleared rapidly. A complete blood count revealed a red cell count of 3.83 mill'n/cmm (normal range 4.2 to 5.7); hemoglobin of 12.9 g/dl (normal range 14.4 to 16.4); and hematocrit of 36.8 percent (normal range 40.6 to 51.8). The pertinent clinical impression was recorded as follows: (1) Status post gastrectomy with vagotomy and postoperative impotence, chronic; and (2) peptic ulcer disease with persistent symptoms requiring periodic antacids. Episodic testicular pain consistent with epididymitis was also noted. The veteran underwent a VA genitourinary examination in December 1993. He said that in September 1982, when he had surgery for his ulcer, he was told by the doctor that it would affect his sex life. He further stated that he became impotent after the operation and, approximately three months later, he underwent surgery for an abdominal aortic aneurysm. He said that he had been totally impotent since immediately after his operation for his duodenal ulcer. His subjective complaint was recorded as not having any sex in 10 years due to inability to have an erection. Clinically, there was a well-healed midline abdominal and xyphoid-to-pubus incision noted. The penis was anatomically intact. It was noted there was no erectile power preserved. The urologist opined that the veteran's abdominal aortic aneurysm caused loss of blood supply to his penis, and this was believed to be the cause of his impotence. The diagnosis was total impotence of at least 10 years' duration caused by an abdominal aortic aneurysm which was subsequently resected with graft. It was again opined that the aortic aneurysm was the cause of obstruction of blood supply to the penis causing the veteran's impotence. II. Analysis The veteran's claims for secondary service connection and an increased rating are well grounded within the meaning of 38 U.S.C.A. § 5107(a). That is, he has presented claims which are not inherently implausible. I am satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required to comply with the duty to assist him. Id. A. Secondary Service Connection for Impotency The veteran claims that his impotency is etiologically related to the gastrectomy and vagotomy he underwent for his service-connected peptic ulcer disease. 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) (1994). In reviewing the clinical records pertaining to the veteran's gastrectomy and vagotomy, I find no suggestion that he was advised that he might incur impotency as the result of the surgery, as he has contended on appeal, and the clinical evidence of record, including the operative report, is completely negative for any findings suggestive of complications from his gastrectomy with vagotomy, including the claimed residual impotency. The only medical evidence of impotency is dated in recent years, consisting of the 1992 and 1993 VA examinations. The only medical evidence of record that arguably is suggestive of the claimed etiological relationship is a VA gastroenterologist's diagnosis following an examination of the veteran in February 1992. A diagnosis of "Status post gastrectomy with vagotomy and postoperative impotence, chronic" was recorded at that time. While the examiner did not specifically link the two, the implication was that the veteran's impotency was a residual of his ulcer surgery. This may have been an impression based upon history obtained from the veteran; there is no indication that the operative report or other pertinent records were reviewed, and the physician did not provide any rationale as to why a gastrectomy with vagotomy would have resulted in impotence. Nevertheless, after the Board's initial review of the matter, it was determined that an opinion from a specialist was desirable. Pursuant to the Board's October 1993 Remand, a VA genitourinary specialist who examined the veteran opined that his impotency was due to obstruction of blood supply from a non-service-connected aortic aneurysm. Thus, the only medical evidence on file that specifically addresses the secondary service connection question goes against his claim. I find that this evidence, which consists of an unequivocal opinion from a specialist that goes to the very question at hand and provides a rationale for the opinion, is highly probative and far outweighs the rather vague, unsupported diagnostic impression that implied a relationship between impotency and ulcer surgery. The veteran has presented no competent medical evidence supporting the contended causal link. The preponderance of the evidence demonstrates that the veteran's impotency was caused by a non-service-connected disability. The benefit of the doubt doctrine is not for application because the evidence is not in equipoise. Accordingly, secondary service connection for impotency is not warranted. B. A Rating in Excess of 20 Percent for Residuals of a Gastrectomy With Vagotomy Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. A duodenal ulcer productive of severe disability or functional impairment, with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health warrants a 60 percent rating. Moderately severe functional impairment, with less than severe disability, but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year is evaluated as 40 percent disabling. Moderate disability, with recurrent episodes of severe symptoms 2 or 3 times a year averaging 10 days in duration, or with continuous moderate manifestations warrants a 20 percent rating. 38 C.F.R. § 4.114, Part 4, Code 7305. Post-gastrectomy syndrome productive of severe functional limitation or disability, associated with nausea, sweating, circulatory disturbance after meals, diarrhea, hypoglycemic symptoms, and weight loss with malnutrition and anemia warrants a 60 percent rating. Moderate functional impairment, with less frequent episodes of epigastric disorders and with characteristic mild circulatory symptoms after meals but with diarrhea and weight loss is evaluated as 40 percent disabling. Mild functional impairment, with infrequent episodes of epigastric distress and with characteristic mild circulatory symptoms or continuous mild manifestations warrants a 20 percent rating. 38 C.F.R. § 4.114, Part 4, Code 7308. Vagotomy with pyloroplasty or gastroenterostomy followed by demonstrably confirmative postoperative complications of stricture or continuous gastric retention warrants a 40 percent rating. With symptoms and confirmed diagnosis of alkaline gastritis, or of confirmed persisting diarrhea, the condition is evaluated as 30 percent disabling. Recurrent ulcer with incomplete vagotomy warrants a 20 percent rating. A recurrent ulcer following complete vagotomy is rated under Code 7305, with a minimum rating of 20 percent; and dumping syndrome is rated under Code 7308. 38 C.F.R. § 4.114, Part 4, Code 7348. Ratings under diagnostic codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 inclusive will not be combined with each other. A single evaluation will be assigned under the diagnostic code which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114 (1994) In reviewing the February 1992 VA gastrointestinal examination report, I find that the only relevant symptoms reported at that time were occasional upper gastrointestinal distress and occasional melena. There is no suggestion of recurrent incapacitating episodes of gastrointestinal distress averaging 10 days or more in duration at least four times a year. His complaint of melena was not confirmed by laboratory examination; the gastroenterologist did not suggest any further examination to evaluate that particular symptom. Blood tests were done but there was no diagnosis of anemia. I have considered the veteran's contention pertaining to an alleged loss of weight, but his weight of approximately 164 pounds noted on the February 1992 examination is precisely the same weight reported upon a VA examination in 1971 and more than the 150 pounds reported upon a VA examination in 1957. Moreover, it was reported on the February 1992 examination that he denied any weight loss. It is also pertinent to point out that there is no indication from the record, including in the veteran's own contentions, that he is receiving any ongoing treatment for his peptic ulcer disease other than antacids. He has correctly pointed out that he was hospitalized on several occasions in 1984 for the service-connected disability at issue, but where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a history of a disability is reviewed to make a more accurate evaluation, the regulations should not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet.App. 55, 58 (1994). It is my judgment that the overall disability picture that has been presented is not consistent with more than moderate functional impairment, within the meaning of Code 7305. I find no indication of a post-gastrectomy syndrome in recent years. The gastroenterologist who examined the veteran in February 1992 did not report such a syndrome, nor were there any circulatory symptoms after meals, diarrhea, or, as noted above, weight loss reported at that time. I find no suggestion of any complications attributable to the partial gastrectomy and vagotomy performed more than 20 years ago, nor does the record indicate alkaline gastritis or a recurrence of an active duodenal or gastric ulcer in recent years. Thus, a higher rating under Code 7308 or 7348 is not warranted. Diagnostic Code 7305 reflects the dominant disability picture and the severity of the overall disability does not warrant elevation to the next higher rating. Nor do the manifestations of the disability more closely approximate the criteria for the next higher evaluation. In fact, no incapacitating episodes are reported. See 38 C.F.R. § 4.7. Finally, there is nothing such as marked interference with employment or frequent hospitalization to warrant an extraschedular rating under 38 C.F.R. § 3.321. As the preponderance of the evidence is against the veteran's claim for an increased rating, the benefit of the doubt doctrine is inapplicable, and the appeal of this issue must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49 (1990). I further find that the disability is not shown to have required frequent hospitalization or to have produced marked interference with employment and, therefore, an extraschedular evaluation under the provisions of 38 C.F.R. § 3.321(b)(1) is not for application. ORDER Secondary service connection for impotency is denied. A rating in excess of 20 percent for residuals of a gastrectomy and vagotomy for peptic ulcer disease 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.