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M21-1, Part III, Subpart iv, Chapter 4, Section I – Genitourinary Disabilities

Overview


In This Section

This section contains the following topics:
Topic Topic Name

1

General Rating Principles for Genitourinary Disabilities
2 Prostate Conditions

3

Erectile Dysfunction (ED)

4

Other Genitourinary Considerations

1.  General Rating Principles for Genitourinary Disabilities


Introduction

This topic contains information about general principles for rating genitourinary disabilities, including


Change Date

January 11, 2018

III.iv.4.I.1.a. Rating Genitourinary Disorders

The diagnostic codes (DCs) for genitourinary disorders are at 38 CFR 4.115b.  Many of those are rated by “dysfunctions” listed in 38 CFR 4.115a.
38 CFR 4.115a provides that diseases of the genitourinary system generally result in disabilities related to renal or voiding dysfunctions, infections, or a combination of these.
  • Where a particular DC lists more than one dysfunction under which the condition can be rated, only the predominant area of dysfunction shall be utilized for rating purposes.
  • When different genitourinary conditions are present and each is evaluated using a different type of dysfunction, separate evaluations may be assigned.

Important:

  • Ensure in every case that rating decisions not pyramid or separate individual findings when those findings in their entirety constitute one disability as discussed at M21-1, Part III, Subpart iv, 5.B.2.b.
  • 38 CFR 4.115a acknowledges that since the areas of dysfunction do not cover all symptoms resulting from genitourinary diseases, specific diagnoses may include a description of symptoms assigned to that diagnosis.
Example:  For pyelonephritis, 38 CFR 4.115b, DC 7504 directs to rate as renal dysfunction or urinary tract infection, whichever is predominant.  If symptoms of both renal dysfunction and urinary tract infection are present and associated with pyelonephritis, assign a single evaluation based on the most disabling symptoms.

III.iv.4.I.1.b.Appliance and Voiding Dysfunction

The term appliance, as used in the criteria for voiding dysfunction under 38 CFR 4.115a, includes all types of catheters, as well as any other assistive device for urination.
Important:  Appliances, including catheters, may be used to treat urine leakage and/or urine retention.  The rating activity should review the evidence carefully to determine whether the appliance is required to treat urine leakage or urine retention and evaluate on the predominant disability.
Example 1:  A Veteran is service-connected (SC) for a bladder injury.  Medical records show a catheter is required for urine leakage due to the bladder injury.
Result:  A 60-percent evaluation should be assigned for this disability based on voiding dysfunction.
Example 2:  A Veteran is SC for a bladder injury. Medical records show a catheter is required for urine retention due to the bladder injury.
Result:  A 30-percent evaluation should be assigned for this disability based on obstructed voiding.
Reference:  For more information on ratings of the genitourinary system based on voiding dysfunction, see 38 CFR 4.115a.

III.iv.4.I.1.c.Evaluating Renal Conditions Using BUN

Do not use elevated blood urea nitrogen (BUN) levels between 20mg% and 40mg% to support a finding of definite decrease in kidney function for assignment of a 60-percent disability evaluation for a renal disability.  BUN values can vary due to many factors such as

  • age and sex of the individual
  • blood loss through the gastrointestinal tract
  • use of steroids for treatment of other chronic diseases
  • level of hydration in the body, and
  • the prescription of too much protein for patients receiving intravenous nutrition in the hospital.

BUN testing is typically employed to screen for kidney disease or for a general assessment of the condition of the kidneys.  BUN is analyzed with respect to the other laboratory values such as creatinine and the glomerular filtration rate (eGFR) to provide a better assessment of kidney function.

Important:

  • Elevated BUN of 40mg% or greater can be used to support an evaluation of 80 or 100 percent for renal disease as described in 38 CFR 4.115a.
  • When the BUN is elevated at greater than 20mg% but less than 40mg%, do not enter the BUN value in the Evaluation Builder or use this value alone to support a finding of definite decrease in kidney function.

III.iv.4.I.1.d.Evaluating Renal Conditions Using Creatinine

Creatinine is a normal breakdown product from muscle which the kidneys cleanse from blood.  As the kidneys become impaired, the creatinine level in the blood will increase due to poor clearance of creatinine by the kidneys.
Creatinine levels above normal but less than 4mg% are abnormal and indicate a definite decrease in kidney function that would warrant a 60-percent evaluation.
Important:  Normal creatinine levels vary between men and women and by laboratory.  The lab report should note the normal level used by that particular laboratory for the patient.
Example:  A Veteran files for an increased evaluation of his SC renal disease, evaluated as renal dysfunction.  He submits a lab report, which notes the lab’s highest normal level is 1.2mg%.  The Veteran’s results show a creatinine level of 1.4mg%.
Result:  Assign a 60-percent evaluation for renal dysfunction under 38 CFR 4.115b.

III.iv.4.I.1.e.  Definition:  Nephritis

 Nephritis is generally defined as inflammation of the kidneys.

III.iv.4.I.1.f.  Characteristics of Nephritis

38 CFR 4.115 discusses several medical concepts pertaining to nephritis. These concepts may be useful in determining when the duty to assist requires an examination or opinion or when medical results may need clarification.

  • Characteristics of glomerular nephritis
    • Usually preceded by or associated with severe infectious disease.
    • Sudden onset.
    • Course marked by red blood cells, salt retention, and edema.
    • May clear up entirely or progress to a chronic condition.
  • Characteristics of nephrosclerotic nephritis
    • Originating in hypertension or arteriosclerosis.
    • Develops slowly.
    • Minimum laboratory findings.
    • Associated with natural progress.
  • Albuminuria alone is not nephritis.
  • Do not accept the presence of transient albumin and casts following febrile illness as establishing nephritis.

III.iv.4.I.1.g. Evaluating Nephritis

Chronic nephritis is addressed in 38 CFR 4.115b, DC 7502.  It is rated as renal dysfunction under 38 CFR 4.115a.  Glomerulonephritis (38 CFR 4.115b, DC 7536) and interstitial nephritis (38 CFR 4.115b, DC 7537) also use the renal dysfunction criteria.

Note:  When nephrosclerosis arises from nephritis, the evaluation criteria under 38 CFR 4.115b, DC 7507 directs that

  • nephrosclerosis be rated according to the predominant symptoms as
    • renal dysfunction
    • hypertension, or
    • heart disease, and
  • if nephrosclerosis is rated under the cardiovascular schedule, the rating which would otherwise be assigned will be elevated to the next higher level.

III.iv.4.I.1.h. Limits on Separate Evaluation of Nephritis and Cardiovascular Conditions

38 CFR 4.115 states that separate ratings cannot be assigned for disability from disease of the heart and any form of nephritis.
The rationale is that there is a close interrelationship between cardiovascular disabilities and nephritis.
Example:
7101
Hypertension
10
7502
Nephritis
60
Assignment of the separate evaluations noted above would not be permitted under38 CFR 4.115 even if the nephritis evaluation was supportable based on definite decrease in renal function.
Exceptions:  Separate ratings for any hypertension or heart disease are permitted in the following scenarios:
  • chronic renal disease has progressed to the point where regular dialysis is required, or
  • if absence of a kidney is the sole renal disability, even if removal was required because of nephritis.
Example:  The following separate evaluations are allowed since absence of the kidney is the sole renal disability.
7500
Kidney – removal of one, history of glomerulonephritis
30
7101
Hypertension
20
Example:  The following separate evaluations are allowed if the 100-percent evaluation for nephritis is based on the requirement for dialysis.
7530
Nephritis
100
7101
Hypertension
10
Reference:  For more information on nephritis, including the different types of nephritis, see

III.iv.4.I.1.i.  Definition:  Nephropathy

Nephropathy is generally defined as a condition encompassing disease or damage of the kidneys.

III.iv.4.I.1.j.  Evaluating Nephropathy

For VA disability purposes, nephropathy is evaluated as renal dysfunction under 38 CFR 4.115a.
The most commonly used DC for nephropathy is 38 CFR 4.115b, DC 7541, “renal involvement in diabetes mellitus,” otherwise known as diabetic nephropathy.

III.iv.4.I.1.k.  Limits on Separate Evaluation of Nephropathy andHypertension

Do not assign separate evaluations for

Explanation:  There is a close interrelationship between hypertension and nephropathy.  Therefore assignment of separate evaluations for hypertension and for renal dysfunction associated with nephropathy violates pyramiding principles under 38 CFR 4.14.  This is true even if the

  • renal dysfunction evaluation appears supportable by criteria other than systolic and diastolic blood pressure (such as definite decrease in kidney function at the 60-percent level or, transient or slight edema at the 30-percent level), or
  • elevated blood pressure is not specifically included in the criteria for the evaluation being assigned, such as at the 80- and 100-percent levels.
Exception:  A separate evaluation for any hypertension is appropriate when
  • nephropathy requires regular dialysis, or
  • absence of a kidney is the sole renal disability — even if removal was required because of nephropathy.
This exception applies because there is no pyramiding of evaluations when the renal rating is for absence of a kidney or for the requirement of regular dialysis.

Important:  The provision of 38 CFR 4.115, which states that separate ratings are not to be assigned for disability from disease of the heart and any form of nephritis, do not apply when evaluating nephropathy becuase nephropathy is a distinct and separate clinical entity.

Reference:  For more information on the prohibition against separating findings that constitute a single disability and pyramiding, see M21-1, Part III, Subpart iv, 5.B.2.b.

2.  Prostate Conditions


Introduction

This topic contains information about prostate conditions, including


Change Date

January 11, 2018

III.iv.4.I.2.a.  BPH

Benign prostatic hypertrophy (BPH) is generally evaluated under 38 CFR 4.115b, DC 7527 based on associated voiding dysfunction or urinary tract infection, but can be evaluated as renal dysfunction or obstructed voiding when applicable.  Consider the following when rating BPH:

  • BPH and some types of treatment for BPH, such as alpha blocker drugs, finasteride, or balloon dilation, can cause incontinence.
  • Retrograde ejaculation can result from some types of BPH treatment, especially transurethral resection of the prostate (TURP).
  • Special monthly compensation (SMC) (k) may be warranted if there is associated erectile dysfunction (ED) or retrograde ejaculation as a result of treatment or if hormone therapy is used.  SMC entitlement is determined on a factual basis.

III.iv.4.I.2.b.Diagnosis of Prostate Cancer by Biopsy

A diagnosis of prostate cancer is made only on the basis of a prostate biopsy.  An elevated prostate-specific antigen (PSA) test is not diagnostic of cancer.
Exception:  A prostate biopsy is not required to support a medical diagnosis that prostate cancer has recurred after radical prostatectomy.  When the initial diagnosis of prostate cancer was confirmed by biopsy and the evidence shows recurrence following any type of treatment, repeat biopsy is not required.  The fact that the diagnosis of recurrence considered PSA does not make the assessment insufficient for rating purposes.  However an assessment should be based on more than PSA results such as, but not limited to, other clinical findings, reports of symptoms, or other medical evidence.

III.iv.4.I.2.c.Rating Prostate Cancer

The table below describes common treatments for prostate cancer as well as the side effects and rating considerations associated with the treatment.

Type of Treatment

Potential Side Effects

Rating Considerations

watchful waiting

  • also called
    • conservative management
    • observation, or
    • surveillance, and
  • no immediate specific therapy is being used, but cancer is active.
  • none, except for the continued presence and potential metastasis of cancer
  • often used when life expectancy is short due to age or other illness since prostate cancer is slow- growing.
  • Review to confirm the continuation of active cancer previously confirmed by biopsy.
  • Evaluate at 100 percent, despite the lack of treatment and possible lack of symptoms.
radical prostatectomy surgery which

  • is characterized by removal of prostate gland and seminal vesicles
  • is the most common treatment for localized cancer
  • can be curative, and
  • may involve a nerve-sparing procedure to improve chances that the patient will retain normal erectile function.
  • impotence, and/or
  • incontinence.
  • In all cases of radical prostatectomy, award SMC (k) for loss of use (LOU) of a creative organ.
  • Consider service connection (SC) for ED on a facts-found basis.
Cryotherapy, also known as cryosurgery or cryoablation, is a procedure by which the prostate and nearby tissues are frozen with liquid nitrogen via probes in the perineum.
  • impotence
  • incontinence
  • urethral scarring, and
  • rectourethral fistula (rare).
Consider SMC (k) on a facts-found basis.
Radiation

  • can be curative if cancer is confined to the prostate and surrounding tissues and PSA is 15 nanograms (ng)/ml or less
  • is also used as palliative therapy to relieve symptoms of advanced cancer, such as bone pain due to metastasis, and
  • can be
    • internal radiation therapy, or brachytherapy, in which radioactive seeds are implanted in the prostate, including
      • high dose radiation (HDR) in which seeds are implanted for less than a day and then removed, and  radiation is present only while seeds are in place, or
      • low dose radiation (LDR) in which seeds are permanently implanted and give off radiation for weeks to months, depending on the radioisotope used, or
    • external radiation therapy, in which radiation is delivered by high-energy eternal radiation for six to eight weeks.
  • after external beam radiation
    • impotence, and/or
    • incontinence
  • after brachytherapy
    • impotence
    • incontinence
    • bowel problems, and/or
    • urethral complications.
  • After internal HDR
    • the radiation continues only for hours or days, so a six-month assignment of temporary 100-percent under 38 CFR 4.115b, DC 7528 is appropriate, and
    • consider SMC (k) for impotence on a facts-found basis.
  • After internal LDR
    • the effective radiation should be gone by one year
    • assign a 100-percent evaluation for one year, and
    • schedule a review exam six months following the cessation of the one-year treatment period.

Note:  If radiation is used only as palliative therapy in advanced cancer, the 100-percent evaluation will continue because the cancer will remain active.  Therefore

  • review for metastatic disease, and
  • consider permanency.
Hormone therapy is primarily for palliation of prostate cancer which is not confined to the prostate for the purpose of testosterone deprivation.

Types of hormone therapy include

  • orchiectomy, the removal of testes to prevent testosterone production
  • luteinizing hormone releasing hormone agonists (LHRH analogs), which can lower the testosterone as effectively as orchiectomy such as
    • Lupron (leuprolide)
    • Zoladex (goserelin), and
    • busrelin
  • estrogens or estrogen-like drugs, which lower the level of testosterone
  • second-line hormonal drugs, which are used when first-line hormone therapy fails
  • anti-androgens, which block the ability of the body to use androgens, such as
    • Eulexin (flutamide)
    • Casodex (bicalutamide), and
    • Nilandron (nilutamide), and
  • combined hormone therapy, which is an anti-androgen combined with orchiectomy or an LHRH agonist (analog).
  • after any hormone therapy
    • hot flashes
    • osteoporosis
    • loss of muscle mass
  • after orchiectomy
    • impotence
    • sterility
    • loss of sex drive
  • after anti-androgen therapy
    • gastrointestinal upset
    • breast tenderness
    • gynecomastia
    • decreased libido
    • impotence
    • hot flashes
  • after LHRH analogs
    • impotence
    • hot flashes, and
    • gynecomastia.
  • Orchiectomy results in anatomical loss of a creative organ; therefore
  • Hormone therapy may continue for many years; therefore
    • review treatment records for expected duration of treatment, and
    • consider permanence.
chemotherapy Depending on the type of chemotherapy used, there are multiple possible side effects. Chemotherapy is used for palliation as current agents will not eradicate prostate cancer; therefore

  • evaluate as 100 percent
  • consider permanence
  • review for metastatic disease, and
  • if metastatic disease affects body systems other than the genitourinary system, award a separate evaluation for confirmed metastatic disease under the appropriate code for that body system.
References:  For more information on

III.iv.4.I.2.d. ED and SMC Due to Prostate Cancer

SC for prostate cancer does not automatically result in
  • SC for ED, or
  • entitlement to SMC (k).
There are various treatments for prostate cancer, such as hormonal therapy, that may result in ED.  Refer to M21-1, Part III, Subpart iv, 4.I.2.c for more information about specific types of treatment and the associated side effects, such as ED or loss of use of a creative organ.
Note:  General guidelines under 38 CFR 3.400 should be followed when determining the effective date for ED.  If ED is the basis for SMC (k), the effective date for the SMC will generally coincide with the date SC is awarded for ED.
Exception:  Radical prostatectomy is a special case.  In all cases where prostate cancer is treated with radical prostatectomy, award entitlement to SMC (k) for LOU of a creative organ without additional examination or medical opinion.
  • Radical prostatectomy results in loss of ejaculatory power and will warrant SMC (k) from the date of the procedure, assuming that the Veteran is already SC for prostate cancer from that date.
  • Entitlement to SC for ED associated with the radical prostatectomy is a separate factual determination.  For the purposes of determining SMC entitlement following radical prostatectomy, it is irrelevant whether ED also exists at the time the SMC is awarded.
Reference:  For more information on when SMC is warranted for ED and other sexual dysfunction, see M21-1, Part III, Subpart iv, 4.I.3.b.

3.  ED


Introduction

This topic contains information about ED, including


Change Date

January 11, 2018

III.iv.4.I.3.a.Deformity of the Penis With Loss of Erectile Power

The following two requirements must be met before a 20 percent evaluation can be assigned for deformity of the penis with loss of erectile power under 38 CFR 4.115b, DC 7522:

  • deformity must be evident, and
  • the deformity must be accompanied by loss of erectile power.

Important:  The condition is not compensable in the absence of penile deformity.


III.iv.4.I.3.b.Entitlement to SMC Associated With ED or Other Sexual Dysfunction

Grant SMC (k) when the evidence shows that SC ED constitutes LOU of a creative organ.  Other diagnoses of sexual dysfunction that may result in LOU include (but are not limited to) loss of libido, loss of sexual drive, or impotence.
When a VA examiner finds that there is ED or other sexual dysfunction, SMC (k) is established even though
  • the Veteran can achieve erection and penetration with the use of medication, or
  • the Veteran had a vasectomy prior to the development of the LOU of a creative organ, as vasectomies may be reversible while LOU is not.
When the evidence, including an examination report or other medical information, shows that a diagnosis of ED or other sexual dysfunction is present but indicates that the Veteran can penetrate and ejaculate without the use of medication, resolve reasonable doubt in the Veteran’s favor and interpret the report to establish that LOU of a creative organ is present and grant entitlement to SMC (k).
Exception:  Do not establish SMC(k) based on an examiner’s finding/conclusion that there is ED if
  • the examination is insufficient for rating purposes because it is not supported by a valid rationale and/or by the evidence of record (for example if the examiner checks that there is ED but there is no history, examination or other basis for the finding)
  • the report is based on the claimant’s report of ED but there is some specific evidence that the claimant’s account of ED lacks credibility, or
  • the preponderance (greater weight) of the evidence proves the contrary.

References:  For more information on


III.iv.4.I.3.c. ED Associated With Multiple Sclerosis or Diabetes Mellitus

When evaluating residuals of multiple sclerosis or diabetes mellitus and associated loss of erectile power is shown but penile deformity is not present, award SC for loss of erectile power rated with the disease process.
Example:  38 CFR 4.119, DC 7913, diabetes mellitus with loss of erectile power.

4.  Other Genitourinary Considerations


Introduction

This topic contains information about other genitourinary considerations, including


Change Date

January 11, 2018

III.iv.4.I.4.a.Residuals of Venereal Disease or HIV-Related Illness

Do not consider specific residuals of venereal disease or human immunodeficiency virus (HIV)-related illness to be the result of willful misconduct.

Determine SC for residuals of venereal disease or HIV-related illness by the same general principles applicable to resolution of the issue of SC for other diseases.
References:  For more information on

III.iv.4.I.4.b.Annual Review of Evaluations Based on Hemodialysis

Each year regional offices (ROs) must review 100-percent evaluations that are based on the need for regular hemodialysis to determine whether the Veteran has discontinued hemodialysis because of kidney transplant surgery.
Follow the steps in the table below to perform this annual review.
Step Action

1

The RO receives 800 series work items for cases under its jurisdiction that contain a single 100-percent genitourinary evaluation.

2

The authorization activity

  • establishes an end product (EP) 680 on each case under review, and
  • refers the case to the rating activity.

3

The rating activity reviews the claims folder.

Do the records show the Veteran has a single 100-percent genitourinary evaluation that is based on the need for regular hemodialysis?

  • If yes, go to Step 4.
  • If no,
    • in a paper claims folder, date, initial, and annotate the write-out or work item NAN (No Action Necessary)
    • in an electronic claims folder (eFolder) in the Veterans Benefits Management System (VBMS)
      • utilize a working note within the bookmark function to date, initial, and annotate the write-out or Work Item NAN, and
      • include a permanent global note indicating the review of the hemodialysis evaluation has occurred, and
    • refer the case to the authorization activity to cancel the EP 680. (This ends the procedure.)

4

Is the evaluation protected under 38 CFR 3.951?

  • If yes,
    • in a paper claims folder, date, initial, and annotate the write-out or work item Evaluation Protected Under 38 CFR 3.951,
    • in an eFolder in VBMS
      • utilize a working note within the bookmark function to date, initial, and annotate the write-out or Work Item Evaluation Protected Under 38 CFR 3.951, and
      • include a permanent global note indicating the review of the hemodialysis evaluation has occurred, and
    • refer the case to the authorization activity to clear the EP 680. (This ends the procedure.)
  • If no, refer the case to the development activity.

5

The development activity advises the Veteran in a locally generated letter that

  • compensation is based on a continuing need for hemodialysis, and
  • he/she must report the date and place of any kidney transplant surgery immediately after undergoing the procedure.

6

The development activity reviews the claims folder to identify the facility where the Veteran is last known to have received hemodialysis.

Do the records show the Veteran last received hemodialysis at a VA facility?

  • If yes,
    • review the Veteran’s records in the Compensation and Pension Record Interchange to confirm that hemodialysis is continuing or to obtain the date of kidney transplant surgery, if hemodialysis has been discontinued, and
    • go to Step 9.
  • If no, go to Step 7.
7
If the claims folder … Then the development activity …
shows the name and address of a non-VA facility where the Veteran last received hemodialysis sends the Veteran a VA Form  21-4142, Authorization to Disclose Information to the Department of Veterans Affairs (VA), and VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA)to authorize VA to obtain the private records.
does not show the name and address of the facility where the Veteran last received hemodialysis sends the Veteran a VA Form 21-4142 and VA Form 21-4142a on which to

  • provide the name and address of the facility furnishing hemodialysis, and
  • authorize VA to obtain the records.

8

Upon receipt of the completed VA Form 21-4142 and VA Form 21-4142a, the authorization activity contacts the facility that last furnished the Veteran hemodialysis to

  • confirm hemodialysis is continuing, or
  • obtain the date of kidney transplant surgery, if hemodialysis has been discontinued.

Note:  If the Veteran does not return the VA Form 21-4142 and VA Form 21-4142a within 60 days, initiate action to adjust the award under38 CFR 3.652.

9

Following completion of development, the RO evaluates each case on the basis of facts found. The authorization activity

  • dates, initials, and annotates the write-out or work item EP 680
  • promulgates the rating decision, if appropriate
  • notifies the Veteran of the action taken
  • clears the EP 680, and
  • if reduction in evaluation under 38 CFR 3.105(e) is necessary, establishes EP 600 for control of the adverse action proposal period.

III.iv.4.I.4.c.Considering Claims for SC of Kidney Donation

Kidney donation and any expected residual effects thereof are not subject to SC. Kidney donation is considered an elective surgery, and therefore, does not meet the provisions of a disease or injury incurred coincident with service.
 Reference:  For more information about the principles relating to SC, see
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