RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01570
BRANCH OF SERVICE:  aRMY	SEPARATION DATE:  20090623

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Cannon Crewmember, medically separated from the Temporary Disability Retired List (TDRL) for “rectum and anus, impairment of sphincter control” and “pruritus ani,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  Conditions should be rated higher.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20090519	VARD - 20080612	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rectum and Anus, Impairment of Sphincter Control	7332	10%	S/P Lateral Sphincterotomy with Incontinence	7332	30%	20071115	
Pruritus Ani	7337-7806	0%	Rectal Eczema with Pruritus Ani	7337-7806	30%	20071204	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Rectum and Anus, Impairment of Sphincter Control.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s sphincter control problem began in January 2002 after a hard airborne landing fall where he noted burning pain in his rectum.  He followed-up at the troop medical clinic, which diagnosed a fissure (small tear in the thin, moist tissue that lines the anus).  The CI underwent a lateral internal sphincterotomy (stretching or cutting muscle in the anal area) in January 2007.  Postoperatively, he developed a rectal abscess, which was incised and drained and was followed by a 5-month course of packing and debridement until the abscess healed.  He continued to have increased fecal urgency and daily rectal itching with fecal incontinence about once a month.

During the 26 November 2007 VA Compensation and Pension (C&P) general examination, 1 month prior to TDRL placement, the CI reported decreased bowel control post-surgery and a history of occasional fecal leakage.  Physical examination showed no anal or rectal stricture, but it was noted the CI had impairment of the rectal sphincter. 

A VA clinic note dated 5 June 2008, 12 months before TDRL removal, showed complaints of perirectal irritation with itching and bleeding whenever he wiped as well as fecal incontinence, which occurred on an irregular basis about once every several months.  Physical examination showed perirectal skin with mild erythema and maceration with just a few small scabs and no active bleeding. 

At the 13 March 2009 TDRL NARSUM examination, 3 months before TDRL removal, the CI reported rectal incontinence resulted in significant difficulties with his job when he worked in the oil fields where a latrine was not readily available and he needed to wear a pad for occasional involuntary bowel movements a few times per month.  As a result of near constant concern about his bowel movements, he left the job.  With his new job he had regular access to a latrine and was able to forgo the use of pads.  He had bowel movements approximately three times per day.  The first was essentially normal; the second often occurred an hour later and was watery; and the third was more variable and occurred later in the day.   He averaged about one episode of incontinence per month and kept extra clothing in his office in case that happened.  Rectal pain improved but occurred if he was constipated or had an episode of increased bowel movement frequency.  Bowel urgency persisted and he felt he had at most 5 minutes to make it to a latrine when he felt the first urge to defecate.  He had no further problems with rectal abscesses or infections.  Physical examination showed decreased sphincter tone.  The examiner noted the sphincter tone and occasional incontinence were largely unchanged since the original PEB proceedings.  There were small skin tags and minor, well-healed scarring.  The erythema previously present prior to TDRL placement had resolved.  There was no tenderness and a digital rectal examination was not painful.  The CI was not using any medication or seeking further treatment options, but came to simply deal with his limitations.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the rectum and anus condition 10%, coded 7332 (rectum and anus, impairment of sphincter control (incontinence)), citing one incontinence episode per month with the need to keep extra clothing at work.  The VA rated the rectum and anus condition 30%, also coded 7332, based on the VA C&P examination, citing “occasional involuntary bowel movements which require wearing of a pad.”

Members noted that a 30% rating using code 7332 requires “occasional involuntary bowel movements, necessitating wearing of pad.”  At the time of TDRL removal latrine facilities were available at his place of employment, but he still experienced about one episode of incontinence a month, which was the same as he experienced prior to TDRL placement.  Although he no longer wore a pad, he had to keep extra clothes in the office should leakage occur.  Members agreed that rapid latrine or bathroom availability and the need for backup clothing were reasonable substitutes for the requirement of wearing of a pad, especially since the pad may well raise the temperature of the perianal area thereby causing sweating and moisture buildup that can exacerbate the pruritus ani (see below) or even contribute to the recurrence of the erythema and dermatitis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the sphincter control impairment, coded 7332.

Pruritus Ani Evaluated as Chronic Dermatitis.  According to the STR and MEB NARSUM, the CI’s pruritus ani-dermatitis condition began approximately in February 2007 after developing a rectal abscess secondary to anal leakage from the aforementioned lateral internal sphincterotomy in January 2007.  Pruritus ani symptoms marked by daily itching persisted after TDRL placement.

During the C&P examination the CI reported itching, burning and soreness which prevented him from prolonged sitting or physical activities that caused friction.  Physical examination showed perirectal eczema with less than 5% of the total body area affected.  A VA clinic note dated 5 June 2008, 12 months before TDRL removal, showed perirectal skin with mild erythema and maceration with just a few scabs and no active bleeding.  The examiner suspected the CI also had a fungal infection.  

At the TDRL NARSUM examination the CI reported pruritus ani symptoms, marked by daily itching after bowel movements that lasted for 15 minutes in the winter and significantly longer in the summer when it was warmer.  Physical examination showed small skin tags and minor well-healed scarring present.  No erythema was present nor was there tenderness to palpation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the pruritus ani-dermatitis 0%, analogously coded 7337-7806 (pruritus ani-dermatitis or eczema), citing less than 5% of body surface area.  The VA rated the pruritus ani-dermatitis condition 10%, also coded 7337-7806, based on the C&P examination, citing severe eczema treated with a topical corticosteroid and bow-legged walk to avoid irritating the area.  The panel noted that the 10% rating requires “evidence of dermatitis or eczema involving at least 5%, but less than 20%, of the entire body, or at least 5%, but less than 20%, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period.”

Although there was pruritus ani with daily itching at the time of TDRL removal, the CI did not use any medication.  Examination revealed no erythema or tenderness present, although there were small skin tags and minor well-healed scarring.  Therefore, members concluded the 0% rating by the PEB was appropriate.  A higher rating is not applicable in the absence of dermatitis or eczema involving at least 5 percent of the entire body or exposed area affected or intermittent systemic therapy or other immunosuppressive drugs.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the pruritus ani condition.

BOARD FINDINGS:  In the matter of the sphincter control impairment, the panel recommends a disability rating of 30%, coded 7332 IAW VASRD §4.114.  In the matter of the pruritus ani condition and IAW VASRD §4.114 and §4.118, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Rectum and Anus, Impairment of Sphincter Control	7332	30%	
Pruritus Ani	7337-7806	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180007950, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure