RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02181
BRANCH OF SERVICE:  Army	BOARD DATE:  20141212
SEPARATION DATE:  20091227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Generator Mechanic) medically separated for recurrent priapism.  The condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The penis deformity condition, characterized as “priapism,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded seven other conditions (adjustment disorder with anxiety, alcohol abuse in early remission, refractive error, myopia astigmatism, right shoulder pain, right knee pain, allergic rhinitis and nicotine dependence) for PEB adjudication.  The Informal PEB adjudicated “recurrent priapism” as unfitting, rated 20%, referencing application of the VA Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting or did not constitute a physical disability.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please review all conditions.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

Service IPEB – Dated 20091006	VA* - (~1 week and 3 weeks Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Priapism…	7599-7522	20%	Priapism	7599-7522	20%	20100114	
Right Shoulder Pain	Not Unfitting	Right Shoulder Rotator Cuff Tendonitis, Labral Tear	5203-5024	10%	20100104	
Allergic Rhinitis	Not Unfitting	Allergic Rhinitis	6522	10%	20100104	
Adjustment Disorder with Anxiety	Does Not Constitute Physical Disability	Adjustment Disorder with Anxiety	9440	0%	20091214*	
Right Knee Pain	Not Unfitting	Right Knee Patellofemoral Pain Syndrome	5261	NSC	20100104	
Refractive Error, Myopia Astigmatism	Not Unfitting	No VA Entry	
Nicotine Dependence	Does Not Constitute Physical Disability	No VA Entry	
Alcohol Abuse in Early Remission	Does Not Constitute Physical Disability	No VA Entry	
Other x 0 (Not in Scope)	Other x 1	
Rating:  20%	Combined:  40%	
*Derived from VA Rating Decision (VARD) dated 20100226 (most proximate to the date of separation (DOS))

ANALYSIS SUMMARY:

Recurrent Priapism.  The narrative summary (NARSUM) noted the CI developed priapism (penile erection for longer than 4 hours and may be unrelated to sexual stimulation) in August 2008 with numerous trips to the emergency room.  The CI was ultimately diagnosed with “stuttering priapism” a rare condition that is recurrent, painful, and is a medical emergency due to the potential to cause ischemic injury (injury due to impaired blood flow).  He underwent many treatment interventions, including multiple injections, an attempted embolization procedure for a suspected arteriovenous fistula (but no fistula was found) and placement of a penile shunt that quickly failed.  He then was treated with hormonal therapy including several subcutaneous (under the skin) implants at 12-week intervals, which improved, but did not eliminate his pain, and an MEB was recommended.

At the MEB examination on 22 April 2009, 8 months prior to separation, the CI reported continued priapism, with intermittent pain, with the hormonal therapy.  The MEB physical exam noted no pertinent positives, except needle stick scars from his treatments.  The drug implants were discontinued in June 2009 due to unwanted side effects from the medication.  The CI had a penile prosthesis implant procedure in June 2009.  Notes in August 2009 indicated that the CI reported continued daily pain that was “tolerable” during the day, but kept him awake at night.  In late August the CI reported increased pain and taking more pain medication and commented “I don’t know why I am having more pain, maybe it is because I am doing more.”  An update to the NARSUM on 4 September 2009 noted that the penile prosthesis implant procedure “helped decrease the severity of the pain but SM still has problem with priapism.”

The CI reported brief suicidal ideation (SI) due to the pain on 18 and 21 September 2009 and in October 2009 he had two emergency room visits for pain in one week.  A urology note on 26 October 2009 indicated that the CI had “chronic baseline regional pain from his condition and takes pain medication on a daily basis,” and noted an abnormal examination with a swollen penis with “baseline fibrotic changes and implant cylinders (deactivated).”  He was prescribed long acting opioid pain medication (Oxycontin) for pain control and reported that it was effective and relieved his pain “completely” for the first time in a year.

At the VA Compensation and Pension (C&P) General examination on 4 January 2010, a week after separation, the CI reported priapism and the examiner noted “he is currently on pain medication ….”  At the C&P Genitourinary examination on 14 January 2010, 3 weeks after separation, the CI reported priapism and urinary symptoms that started after the penile implant surgery.  The CI reported pain with use of the prosthesis and that the prosthesis was required for sexual intercourse.  On examination there was scarring of the penis and “decreased sensation, decreased reflexes, decreased peripheral pulses and there was no fistula [abnormal connection between an organ, vessel or intestine to another structure].”  Medication was listed as Oxycontin as needed.

At a C&P Mental Disorders examination on 4 April 2011, approximately 15 months after separation the CI reported that priapism continued for months after the implant surgery, but had now resolved, but that he required assistance of the implant.  He reported consistent pain with sexual activity.  There was no mention of chronic pain.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the priapism condition 20%, coded 7599-7522 (analogous to penile deformity with loss of erectile power).  The Board considered evidence in the record that supports the CI’s priapism condition resolved within months after the penile prosthesis implant procedure/surgery.  The CI continued to report residuals of dependence on the implant for sexual activity, he had consistent pain with sexual activity and he had effective pain relief with medication.  The Board agreed that the disability met the 20% rating under 7522 IAW §4.115b (genitourinary system) and considered if there was any path to a higher rating, noting that a 20% rating is the only available rating under code 7522.  Members discussed whether elevation to a 30% rating could be recommended based upon consideration of functional impairment IAW VASRD §4.10, but dismissed this approach because code 7522 provides a single rating option of 20%, without subjective latitude involved in the rating criteria.  The Board engaged in lengthy deliberations regarding the appropriate coding and rating of the CI’s disability due to the painful priapism condition.  Board consensus was that analogous coding, whether IAW §4.115b or IAW §4.124a (neurological disorders) for chronic pain, was not appropriate in this case because the VASRD provides codes for penile loss or dysfunction.  There was no evidence to support full or partial loss of the organ; and thus the majority opinion was that the most appropriate code for the condition was 7522.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board consensus concluded that there was insufficient cause to recommend a change in the PEB adjudication for the priapism condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the refractive error-myopia astigmatism, right shoulder pain, right knee pain, allergic rhinitis and nicotine dependence 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.

Refractive Error-Myopia Astigmatism.  The DD Form 2808, Report of Medical Examination, noted mild decreased distance vision in the right eye 20/30 (normal 20/20 or better) and normal vision in the left eye.  The NARSUM notes that the CI had myopia without other eye symptoms or findings and noted refractive error-myopia astigmatism that met retention standards.  The original VARD did not address any eye condition.

Right Shoulder Pain.   The NARSUM noted the CI had mild right shoulder pain that required no medication and that met retention standards.  On the MEB examination CI was noted to be right hand dominant and have full range-of-motion (ROM) of the right shoulder with mild tenderness and crepitus.  The original VARD 26 February 2010 cited the VA C&P examination which noted right shoulder pain with flexion of 170 degrees and abduction of 180 degrees, without any instability or dislocation, or additional loss of ROM with repetition of ROM.  The VA rated the right shoulder 10%.

Right Knee Pain.  The CI reported mild right knee pain that did not require medication.  On the MEB examination there was mild pain and crepitus of the right knee with no evidence of instability or cartilage damage.  The NARSUM noted the CI had a history of Osgood Schlatter’s disease of the knee but there was no evidence of that on examination.  The MEB NARSUM indicated the right knee pain met retention standards.  The VA did not service-connect the right knee condition.  The original VARD dated 26 February 2010 cited the VA C&P examination which noted right knee radiographs and examination were normal.  The VA did not service-connect the right knee condition.

Allergic Rhinitis.  The NARSUM noted allergic rhinitis that met retention standards.  Medications included pseudoephedrine (episodic allergy medication).  Examination of the eyes, ears, nose, throat and lungs was normal.  The original VARD on 26 February 2010 cited the VA C&P examination which noted swelling of the nasal cavities with watery discharge without obstruction or polyps.  The VA rated allergic rhinitis 10% 

The refractive error-myopia astigmatism, right shoulder pain, right knee pain and allergic rhinitis, conditions were not profiled and were not judged to fail retention standards.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  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 determination for any of these contended conditions and so no additional disability ratings are recommended.

Nicotine Dependence.  The NARSUM notes that the CI smoked a pack of cigarettes per day for 3 to 4 years.  The original VARD did not address nicotine dependence.  Nicotine dependence is a substance use disorder and IAW DoDI 1332.38, enclosure 5 is a condition not constituting a physical disability and is not eligible for a disability rating.

Adjustment Disorder with Anxiety Condition (to include Alcohol Abuse in Early Remission).  The PEB determined that the adjustment disorder with anxiety and alcohol abuse in early remission were conditions not constituting physical disabilities IAW DoDI 1332.38, enclosure 5.  The Board reviewed the record for evidence of any unfitting mental health (MH) disorder at the time of separation, regardless of a specific MH diagnosis.

The MEB Psychiatric addendum on 28 August 2009 noted that the MEB was initiated for a non-MH condition and the CI was being treated for alcohol abuse with a history of depression and adjustment disorder.  The CI reported an annoyed and irritated mood with worry all day about a loss of rank due to an Article 15, dealing with his medical issues and being ridiculed at work for his medical diagnosis.  The CI noted that he thought his deployment experiences were traumatic, but denied intrusive thoughts, hyperarousal, emotional numbing due to his experiences or traumatic brain injury.  He reported sleep difficulties due to physical pain and SI due to the pain recently, but none currently, and no panic attacks or psychotic symptoms.  The CI reported alcohol consumption started following his physical problems, to deal with the pain and stress.  He referred himself for substance abuse treatment in March 2009 and admitted to a few relapses, but denied other substance abuse.  The CI was living at the Warrior Transition Unit (WTU).  He reported good primary family relationships, but was separated from his wife.  Mental status examination (MSE) was normal.  The examiner’s summary of the commander’s statement is excerpted below:

“. . . the 06MAR09 Commander’s Performance and Functional Statement . . . reflects that the service member performs current duties alternative to the assigned MOS well; and that this service member does not have any appreciated deficits in industrial capacity, and comments “[his] performance on rear-detachment has been outstanding, he is a very hard worker, and will complete whatever mission to standard.””

The MEB psychiatrist noted the CI had episodic situational coping difficulties and that the alcohol abuse was in remission.  The Axis I diagnoses were adjustment disorder with anxiety and alcohol abuse in early remission with a Global Assessment of Functioning of 70 (mild to minimal impairment range).  The psychiatrist noted that adjustment disorder does not require disability rating by the PEB IAW AR 40-501, paragraph 3-36.  Notes in the service treatment record supported the MEB psychiatric addendum and also noted situational stress due to command and unit members’ management of, and reactions to, the CI’s medical issues.  Following a more successful surgical treatment in June 2009, the CI reported not drinking, moved to the WTU, and reported that he was feeling more positive.  However, notes in September 2009 indicated the CI’s physical pain as well as personal situational stressors increased and he was diagnosed with depressive and anxiety disorders.  He had been prescribed an anti-anxiety agent (Klonopin) which was stopped and now was on an antidepressant medication (Effexor).  The final MH note in the record on 21 October 2009 before the PEB noted a normal MSE.  The psychiatric profile was S1 throughout service.

The Board considered that the commander’s performance statement excerpted by the MEB NARSUM examiner indicated continued excellent performance by the CI within his physical profile limitations; the psychiatric profile was S1 throughout service and there is no evidence in the STR documenting adverse performance due to MH issues.  The Board agreed that even if another potentially ratable MH diagnosis, such as anxiety or depression, was conceded for consideration, there would be insufficient evidence for recommending it as unfitting and eligible for 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 adjudication of the MH conditions and, therefore, no additional disability rating can be 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 priapism condition and IAW VASRD §4.115b, the Board unanimously recommends no change in the PEB adjudication.  In the matters of the contended refractive error-myopia astigmatism, right shoulder pain, right knee pain, allergic rhinitis, conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  In the matters of the contended MH, alcohol abuse and nicotine dependence conditions, the Board unanimously recommends no change of the PEB adjudications.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends no recharacterization of the CI’s disability and separation determination.

RECOMMENDATION:  The Board, therefore, recommends there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140516, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXX, AR20150014208 (PD201402181)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     

CF: 
(  ) DoD PDBR
(  ) DVA