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AF | PDBR | CY2012 | PD2012 00903
Original file (PD2012 00903.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1200903
BRANCH OF SERVICE: Army  BOARD DATE: 20130508
SEPARATION DATE: 20020802


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (19K, Armor Crewmember) medically separated for testicular pain. The CI had a long history of scrotal pain along with blood and white blood cells in his urine. Treatment included medications and two surgical interventions. Despite these treatments the conditions could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards. He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). The testicular condition, characterized as “chronic testicular pain secondary to recurrent epididymitis” was forwarded to the Physical Evaluation Board (PEB). The MEB also identified and forwarded four other conditions (see rating chart below) for PEB adjudication. The PEB adjudicated “chronic left testicular pain” as unfitting and rated 0%. The remaining conditions were determined to be not unfitting . The CI made no appeals and was medically separated with that 0% disability rating.


CI CONTENTION: “Continually worsening chronic pain (testicular pain), several VA urologist (latest was Main Urologist in Kansas City) stated "the VA has exhausted all means necessary to treat and repair your condition.”


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting left testicular pain condition is addressed below. MEB diagnoses of chronic hematuria, chronic pyuria, right varicocele and urethral strictures found not unfitting by the PEB, are also addressed below. Any conditions or contention not requested in this application or otherwise outside the Board’s defined scope of review remain eligible for future consideration by the Service Board for Correction of Military Records.


RATING COMPARISON:

Service PEB – Dated 20020510
 VA - (~13 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Left Testicular Pain, Rated as Moderate
 8799-8730 0% Epididymitis with Right Side Varicocele, Urethral Stricture and Bilateral Testicular Pain 7599-7518 10% 20030930
Chronic Hematuria
 Not Unfitting
Chronic Pyuria
Symptomatic Varicocele, Right Side
Urethral Strictures, Soft
No Additional MEB/PEB Entries
 Other x 4 20031007
Combined: 0%
 Combined: 10%
Derived from VA Rating Decision (VA RD ) dated 20040210 .


ANALYSIS SUMMARY: The PEB rated chronic left testicular pain as unfitting and provided a disability rating. The PEB adjudicated the other forwarded MEB findings of chronic hematuria and pyuria as not unfitting. The Board notes for clarification that hematuria (blood in urine) and pyuria (white cells in urine) are findings of laboratory tests routinely performed to evaluate genitourinary symptoms. Laboratory test findings cannot be unfitting in and of themselves; they can only reflect an unfitting condition. Therefore, the chronic hematuria and pyuria are part and parcel of the unfitting left testicular pain condition addressed below. The symptomatic right varicocele and urethral stricture conditions will be addressed under contended conditions.

Testicular Pain and Associated Conditions . The narrative summary (NARSUM) notes the CI had a long history of chronic scrotal pain due to recurrent epididymitis with associated laboratory findings of blood and white cells in the urine. The CI was seen multiple times throughout his career for this and evaluations included cultures for infection which were always negative (including for tuberculosis). Service treatment records (STR) indicated that the CI had a history of an episode of incomplete testicular torsion in approximately 1986 but none since. The CI had a full urological evaluation 30 April 2001 and the impression was recurrent infections and a left varicocele. The CI had an intravenous pyelogram which showed no abnormalities of the kidneys or renal collecting system. Cystoscopy 23 May 2001 showed a normal bladder without evidence of tumors or stones. There were several soft strictures in the urethra, thought to account for the pyuria. The CI next had procedures 9 August 2001 to dilate the urethral strictures again and to ligate a left varicocele. The STR indicated at the follow-up urology visit the CI was doing well with minimal pain. At the next follow-up the CI had no significant pain in his left testicle except for an occasional shooting pain or pulling when he moved; right testicular pain was not noted. He returned to his duties and 2 weeks later and was examined again for a swollen left testicle during which he reported pain with activity of standing, running, or jumping rated 7-8 out of 10. He continued with groin pain much greater on the left than the right. At the MEB exam 10 March 2002 (approximately 5 months prior to separation) the CI reported chronic scrotal pain rated 2 out of 10 at baseline but increasing to 8 out of 10 with strenuous activity. The MEB physical exam noted the right and left epididymi were tender, and the left testis was tender to palpation without other abnormality. A small right varicocele was noted on exam. There was no evidence of kidney or other genitourinary tract infection. At the VA Compensation and Pension (C&P) exam 30 September 2003 (approximately 13 months after separation) the CI reported bilateral testicular pain, hematuria, difficulty with urination, night time voiding one time per night, daytime voiding four to five times per day, no urinary incontinence, but reported penile discharge. The CI reported no erectile dysfunction but some pain with ejaculation. The VA examiner noted that CI was treated multiple times for presumed infection with diagnoses of urinary tract infection, epididymitis and one episode of prostatitis, with negative cultures and without evidence of kidney infection. The CI’s workup was negative for kidney or bladder stones. He had not been hospitalized and did not need catheterizations or repeat dilatations. The VA exam showed the testicles were normal bilaterally with some tenderness. The prostate was described as normal size, boggy and tender.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the testicular pain condition as 8799-8730 (analogous to partial paralysis of the ilio-inguinal nerve) at 0%. The VA rated the condition as 7599-7518 (analogous to urethral stricture) at 10%. The Board deliberated rating of the CI’s testicular pain condition IAW §4.124a (schedule of ratings - neurological conditions and convulsive disorders) or §4.115b (ratings of the genitourinary system-diagnoses). The Board agreed that the CI’s condition was most appropriately rated IAW §4. 115b. The CI’s history, based on evidence in the records available, included treatment for multiple episodes of infection of the genitourinary tract – urinary tract infection, prostatitis and multiple episodes of epididymitis, with an eventual diagnosis of chronic epididymitis. He was also treated for urethral strictures twice within a month without subsequent dilations. At the C&P exam he reported symptoms of testicular pain, difficult or painful urination, painful ejaculation without erectile dysfunction, voiding frequency was documented as four to five times per day (once every 3-4 hours in a 16 hour day), and voiding once per night. IAW §4.115b., “Diseases of the genitourinary system generally result in disabilities related to renal or voiding dysfunctions, infections or a combination of these.” And further “….only the predominate area of dysfunction shall be considered for rating purposes.” There was no evidence in the record of renal function abnormalities. The Board opined that the predominate genitourinary dysfunction in this case was related to recurrent episodes of presumed infection, characterized as recurrent or chronic epididymitis, which met the 10% evaluation of 7599-7525 (chronic epididymo-orchitis). The Board reviewed to see if a higher rating was achievable rating as 7518 (urethral stricture) and found that it was not, as there was no evidence of “marked obstructive symptomology (hesitancy, slow or weak stream, decreased force of stream)” or “daytime voiding interval between two and three hours or night time voiding two times per night” in the record. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the testicular pain condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the right varicocele and urethral strictures conditions were not unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations but remains adherent to the DoDI 6040.44 “fair and equitable” standard. 1). Right varicocele. In remote records from the early 1990’s there are notes referring to pain of both testicles followed by notes indicating groin pain. Notes beginning with the initial urologic evaluation 30 April 2001 referred only to the left testicle pain. The urology visit November 2001 noted a mild right varicocele. A clinic treatment note 8 March 2002 noted “chronic testicular pain” and indicated bilateral, but noted the right was much less than the left, since 1991. 2). Urethral Stricture. The CI was noted to have soft urethral strictures at the time of his first urologic evaluation in April 2001. A second cystoscopy was performed in August 2001 to dilate the urethral strictures more thoroughly. Following that procedure there are no further notes in the record referring to pain with urination or voiding dysfunction and no repeated urethral dilatations. The right varicocele was listed on the permanent profile as part of the chronic testicular pain condition, as were the other not unfitting laboratory test findings of hematuria and pyuria. The urethral strictures were not permanently profiled. The commander’s statement noted the CI’s chronic testicular problems, but further referred to them as due to his previous surgeries which involved the left testicle, but not the right. All were reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that the right varicocele or urethral strictures significantly interfered with satisfactory duty performance. The Board noted that even if the right testicular pain was significant there is no way to separate the effects of the left testicle from the right; the disability effects are considered together as scrotal contents. The Board additionally reviewed coding IAW §4.115b as 7518 (urethral stricture) when rating the left testicular pain condition and found that it did not lead to a compensable rating. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determinations for the right varicocele and urethral stricture conditions, therefore no additional disability ratings are recommended.


BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the chronic left testicular pain condition, the Board unanimously recommends a disability rating of 10%, coded 7599-7525 IAW VASRD §4. 115b. In the matter of the right varicocele and urethral stricture conditions and IAW VASRD §4.115b, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Chronic Left Testicular Pain Condition
 7599-7525 10%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120610, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20130011099 (PD201200903)
1. I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:




Encl                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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