RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01250
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20040806

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Electronic Warfare Journeyman, medically separated for “post vasectomy scrotal pain associated with pain disorder” with a disability rating of 10%.  

CI CONTENTION:  The CI made no specific contention.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (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 or non-compensable.  Any conditions outside the panel’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 Records.  Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 PEB - 20040526	VARD – 20050328 & 20051006	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Vasectomy Scrotal Pain associated with Pain Disorder	8530	10%	Post Vascular Pain Syndrome, Left Sided Varicocele, and Bilateral Hydroceles	7599-7509	10%	20041104	
			Pain Disorder	9422	NSC	20050517	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:

Post Vasectomy Scrotal Pain associated with Pain Disorder.  The PEB combined the chronic post-vasectomy scrotal pain and pain disorder associated with both psychological factors and a general medical condition diagnoses under a single disability rating, coded 8530 (paralysis of the ilioinguinal nerve).  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the scrotal pain condition and pain disorder are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Post Vasectomy Scrotal Pain:  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s scrotal pain began in April 2002 after receiving an elective vasectomy and being kicked in the scrotum during the post-operative period.  The CI later developed constant scrotal pain which worsened with physical activity or ejaculation.  Following specialist evaluations from physical therapy, pain management, and urology, the CI declined nerve blocks or surgery (vasovasostomy) and elected to continue conservative therapy.  An ultrasound performed on 18 September 2003 showed small bilateral hydroceles and a left sided varicocele.  

The 27 April 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic dull post-vasectomy scrotal pain, with episodic lancinating pain that increased in frequency and severity.  The CI denied dysuria (pain or difficulty urinating), hematuria, erectile dysfunction, discharge, lesions, scrotal mass, or swelling.  Physical examination showed a circumcised male whose testicles were descended bilaterally without mass.  Scrotal structures were non-tender.  There were no lesions or discoloration on the genitals.  The final diagnosis was chronic post-vasectomy pain, and the physician indicated that medical and pharmacological care had been exhausted and that the CI was impaired because of his chronic pain that significantly impacted his duty performance.  

At the 4 November 2004 VA Compensation and Pension (C&P) general medical examination, 3 months after separation, the CI reported chronic vasectomy pain which prevented him from performing exercises, or activities such as operating a vacuum, driving a car, climbing stairs, or taking out the trash due to pain; and also experienced pain during intercourse.  The CI had not missed work and was not receiving treatment for the condition.  Physical examination of the genitals was normal.  There was no evidence of genital deformity or urinary incontinence.  

The panel directed attention to its fitness and rating recommendation based on the above evidence.  The PEB rated the post vasectomy scrotal pain (combined with the pain disorder condition) at 10%, coded 8530 (paralysis of the ilioinguinal nerve).  The VA also rated the post vasecular pain syndrome, varicocele, and bilateral hydrocele condition at 10%, coded analogously to 7509 (hydronephrosis), based on the C&P examination 3 months after separation, citing left-sided varicocele, bilateral hydrocele, and constant scrotal pain as a result of a vasectomy.  

The panel first considered if the post vasectomy scrotal pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members agreed the evidence reasonably justified that the functional limitations of the condition was the underlying and principle disability that contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.  The 10% adjudicated by the PEB, is the highest available VASRD rating under code 8530.  The panel considered alternative rating under VASRD genitourinary system codes (VASRD §4.115b) similar to the VA’s rating, but all were less applicable and/or not advantageous to rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the post vasectomy scrotal pain condition.  

Pain Disorder:  The CI was being seen in Life Skills for psychologic counselling in relation to his ongoing pain problem since 26 November 2003 in the setting of post-vasectomy pain.  The MEB forwarded pain disorder associated with both psychological factors and a general medical condition for PEB adjudication.  

The 5 April 2004 MEB NARSUM Psychiatric examination, 4 months prior to separation, related the CI’s ongoing mental health treatment related to ongoing pain problems.  Multiple pain medications including narcotics and neuroactive medications had not relieved the CI’s pain.  Psychiatry found mood problems highly associated with the pain problem and psychotropic medication (Celexa) was started in November 2003 and stopped in three weeks due to side effects.  In January 2004, the CI declined alternate psychotropic medications.  The clinical diagnosis was pain disorder, and the CI declined ongoing counseling, until after the MEB NARSUM was written.  On mental status examination (MSE), his mood was described as “cloudy” and the affect was somewhat restricted.  Speech pattern was characterized by a depressed tone, slow rate, and low volume.  “Insight was poor; (the CI) ha[d] become angry when a provider hint[ed] at emotional contribution to his pain.”  There was no suicidal ideation, delusions, hallucinations or other symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment, or other abnormality.  The psychiatrist diagnosed pain disorder associated with both psychological factors and a general medical condition, chronic.  The examiner indicated that the CI’s “pain problems have had severe effects on his social and occupational functioning” and that impairment for social and industrial adaptability was marked.  The Global Assessment of Functioning (GAF) was 60 (60 - 51 range is moderate symptoms).  The clinical psychologist visit on 22 April 2004 showed a diagnosis of adjustment disorder, but this diagnosis was not continued on subsequent psychologist visits on 3 May, 24 May, and 29 June 2004 (1 month prior to separation).  All four evaluations documented a normal mood and essentially normal MSEs.  

At the 17 May 2005 C&P Mental Disorders examination, 11 months after separation, the CI complained of continued groin pain and poor sleep.  The CI was working and had a good marriage and social functioning.  The MSE was unremarkable.  The examiner diagnosed Axis I adjustment disorder with depressed mood and Axis III pain disorder associated with a general medical condition.  The GAF was 70 and “reflect[ed] mild depression and some difficulty with irritability (some mild symptoms).  The examiner summarized that the CI did not meet the (Axis I) criteria “for a diagnosis of pain disorder associated with psychological factors because it [did] not cause major disruption in social, personal, or occupational functioning at [the] time.  Furthermore, it [did] not appear that psychological factors cause[d] exacerbation or maintenance of the pain.”  He further explained that the Axis III diagnosis of pain disorder associated with a general medical condition is diagnosed when psychological factors play no more than a minimal, if any, role in the pain and it is not considered a mental disorder.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the pain disorder with the post vasectomy scrotal pain condition (8530 at 10%) as detailed above, and there was no separate mental disorder coding or rating.  The VA denied service connection for adjustment disorder with depressed mood indicating that although there was a record of in-service treatment for pain disorder, that the CI’s mental disorder diagnoses were not static and that there was no permanent residual or chronic disability subject to service connection by STR or evidence following service.  The panel adjudged that there was pre-separation improvement of the pain disorder and that it was appropriately combined with the underlying medical condition of chronic post-vasectomy scrotal pain.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB combined adjudication for the post vasectomy scrotal pain and pain disorder.  

BOARD FINDINGS:  In the matter of the post vasectomy scrotal pain and pain disorder and IAW VASRD §4.124a and §4.115b, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160925, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01250.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  The Board recommended no re-characterization or modification of your separation.

I carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings