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Section A – Disabilities of the Gynecological System
Updated Nov 15, 2021

In This Chapter

 This chapter contains the following topics:
Topic Topic Name
1 General Rating Principles for Genitourinary Disabilities
2 Evaluating Nephritis and Nephropathy
3 Prostate Conditions
4 Erectile Dysfunction (ED)
5 Other Genitourinary Considerations

1.General Rating Principles for Genitourinary Disabilities

Introduction

 This topic contains guidance on the general principles for evaluating genitourinary dysfunction, including

Change Date

 November 15, 2021

V.iii.7.1.a.Rating Genitourinary Disorders

 The diagnostic codes (DCs) for genitourinary disorders are at 38 CFR 4.115b.  Many of those are rated by the rating formulas for dysfunction provided in 38 CFR 4.115a.  The three types of genitourinary dysfunction are
  • voiding dysfunction, which provides evaluations based on
    • frequency
    • leakage, and/or
    • obstructed voiding
  • urinary tract infections, and
  • renal dysfunction.
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.  Separate evaluations may not be assigned for different types of dysfunction attributable to a single condition.
  • When different genitourinary conditions are present and each is evaluated using a different type of dysfunction, separate evaluations may be assigned.
  • When different genitourinary conditions are present but each is evaluated using the same type of dysfunction, separate evaluations may not 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 V, Subpart ii, 3.D.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.

V.iii.7.1.b.Renal Dysfunction

 Renal dysfunction is evaluated using specific, objective laboratory findings.
  • Glomerular filtration rate (GFR) is widely accepted as the best overall measure of kidney function in health and disease.  There is an inverse correlation between GFR and functional impairment.
    • Lower GFRs correspond to greater impairment.
    • Individuals with GFRs less than 60 mL/min/1.73 m2 are considered to have chronic renal disease.
    • A GFR less than 15 mL/min/1.73 m2 is a sign of renal failure.
    • GFR, estimated GFR (eGFR), and creatinine-based approximations are acceptable for evaluation purposes, as each has been shown to be an adequate indicator of the stage of chronic kidney disease.  Elevated creatinine levels are correlated with decreasing GFR.
  • Proteinuria, as measured by increased urinary excretion of albumin, is an early and sensitive maker of kidney damage and is reflected by an albumin/creatinine ratio (ACR) of 30 mg/g or greater.

V.iii.7.1.c.Determining Chronicity of Renal Dysfunction

 Assignment of a compensable evaluation for renal dysfunction based on abnormal GFR or (other findings accepted for evaluation purposes under 38 CFR 4.115a) is premised upon findings spanning over three consecutive  months. Satisfaction of the three-month requirement does not necessitate an individual finding in each month of a three-month period.  Rather, clinical data showing an abnormal finding with another repeated abnormal finding 3 or more months later during a 12-month period will document chronicity of the impairment and will be sufficient to satisfy this requirement unless there is evidence to the contrary. It is expected that an individual with chronic renal dysfunction would be followed for treatment and clinical data would be sufficient to document chronicity of findings over the three month or longer period. However, when such clinical data is unavailable to decision makers, a one-time finding may be used to assign the corresponding disability evaluation unless there is evidence that suggests non-chronicity of the impairment.
  • When a compensable evaluation is assigned based on a one-time finding of abnormal GFR, defer the end product and schedule an at-once examination to obtain a second GFR reading three months after the first.
  • This at-once examination is necessary to satisfy the regulatory requirement for sustained findings from a three-month period.
Reference:  For more information on handling improvement shown on the at-once examination, see

V.iii.7.1.d.Use of Catheters and Other Appliances

 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 associated with voiding dysfunction and/or urine retention associated with obstructed voiding.  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. Note:  For the purposes of evaluating urinary tract infection at the 30-percent rate, the use of catheters is not considered comparable to drainage by stent or nephrostomy and is inconsistent with the remainder of the criteria required for a 30-percent evaluation.  Stent and nephrostomy tube insertion are surgical procedures and require more intensive management than drainage by catheterization. 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.

V.iii.7.1.e.Urinary Tract Infection

 The following terms are utilized in the criteria for evaluating urinary tract infection. Suppressive drug therapy, as identified in the criteria for the 0- and 10-percent disability evaluations, refers to the use of prolonged suppressive antibiotic therapy or medications for treatment of urinary tract infections.  The required duration of the therapy is identified in the rating criteria. Continuous intensive management, as identified in the criteria for the 30-percent disability evaluation, refers to the requirement for treatment beyond the use of antibiotic or other medications or hospitalizations as described in the 0- and 10-percent evaluation levels.  Examples of this level of care include but are not limited surgical management of the nephrostomy and/or stent, intravenous antibiotics, or treatment that is otherwise required for the maintenance of the nephrostomy tube or stent.

V.iii.7.1.f.Recurrent Stone Formation

 Under 38 CFR 4.115b, DC 7508, a 30-percent disability evaluation is assigned when evidence shows recurrent stone formation requiring invasive or non-invasive procedures more than 2 times per year.
  • Examples of therapeutic procedures that would satisfy these requirements include (but are not limited to)
    • invasive procedures, such as
      • open surgical lithotomy
      • percutaneous nephrolithotomy (PCNL)
      • retrograde intrarenal surgery (RIRS), or
      • other minimally invasive endourological treatments, and
    • non-invasive procedures, such as
      • shockwave lithotripsy (SWL), or
      • ureteroscopic fragmentation and retrieval.
  • Recurrent stone formation means that there must be more than one episode of stone formation requiring treatment during a one-year period.

V.iii.7.1.g.Changes in the Rating Schedule for the Genitourinary System

 The rating criteria for the genitourinary system have undergone historical changes.  Recent full-scale revisions were effective on the following dates:
  • November 14, 2021, and
  • February 17, 1994.
Note:  These changes in the rating criteria
  • are not considered liberalizing, and
  • should not be the basis for a reduction in disability rating unless medical evidence establishes that the disability has actually improved.

2.Evaluating Nephritis and Nephropathy

Introduction

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

Change Date

 November 15, 2021

V.iii.7.2.a.Definition:  Nephropathy

 Nephropathy is generally defined as a condition encompassing disease or damage of the kidneys.  Nephropathy is a broader term to describe any condition that impairs renal function. Examples of nephropathy include (but are not limited to) chronic renal disease, nephrotic syndrome, and nephritis.

V.iii.7.2.b.Evaluating Nephropathy

 For Department of Veterans Affairs (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 type I or II,” otherwise known as diabetic nephropathy. Important:  When the renal impairment is a form of nephritis, 38 CFR 4.115 applies as discussed in M21-1, Part V, Subpart iii, 7.2.f.

V.iii.7.2.c.Evaluation of Nephropathy and Hypertension

 The provision of 38 CFR 4.115 that states that separate ratings are not to be assigned for disability from disease of the heart and any form of nephritis does not apply when evaluating other types of nephropathy because nephropathy is a broader diagnostic classification warranting its own evaluative approach.  Other types of nephropathy may be assigned separate evaluations for the renal impairment and heart disease and/or hypertension.
Note:  Prior to the revision of 38 CFR 4.115a effective on November 14, 2021, hypertension was included among the criteria for evaluation of renal dysfunction.  Consequently, under the historical criteria, separate evaluations could not be assigned for hypertension and nephropathy except when dialysis was required or when the condition was characterized by absence of the kidney as assignment of separate evaluations would have been in violation of 38 CFR 4.14. Reference:  For more information on the historical prohibition against separate evaluations for hypertension and nephropathy in place prior to November 14, 2021, see
  • 38 CFR 4.14, and
  • the attachment titled Historical_M21-1V_iii_7_9-15-21.

V.iii.7.2.d.Definition:  Nephritis

 Nephritis is generally defined as inflammation of the kidneys.  It includes inflammation of any renal structure such as glomeruli, tubules, or interstitial tissue. Nephritis is a form of nephropathy.

V.iii.7.2.e.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 symptoms, such as elevated albumin and the presence of casts following febrile illness as establishing nephritis.

V.iii.7.2.f.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.

V.iii.7.2.g.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 1:  The following separate evaluations are not permitted under 38 CFR 4.115 even if the nephritis evaluation was supportable based on definite decrease in renal function.
7101 Hypertension 10
7502 Nephritis 60
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 2:  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 3:  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

V.iii.7.2.h.Distinguishing Nephritis From Other Types of Nephropathy

 Although a condition may be diagnosed as nephropathy, the evidence must be carefully examined to determine if the diagnosed nephropathy can be clinically recognized as a form of nephritis that would trigger 38 CFR 4.115 application.
  • A nephropathy diagnosis is not dispositive for the purpose of making this distinction.
  • Additional review of the evidence beyond the given diagnosis will be necessary to determine whether the renal condition, irrespective of the diagnosis, is a form of nephritis.
In the following examples, the diagnosis contains the term “nephropathy” but the disability is actually a type of nephritis and must be evaluated with consideration of 38 CFR 4.115.
  • IgA nephropathy is generally characterized clinically as a type of primary glomerulonephritis.
  • 38 CFR 4.115b, DC 7537 is the DC for interstitial nephritis, and gouty nephropathy is identified as a type of interstitial nephritis as well as other disorders of calcium metabolism.
Important:
  • When the clinical evidence is unclear, request a medical opinion to determine whether the disability in question is a type of nephritis.
  • It is impermissible to evaluate a type of nephritis specifically identified in the rating schedule, such as gouty nephropathy, by analogy in an effort to achieve a higher disability evaluation.

3.Prostate Conditions

Introduction

 This topic contains information about prostate conditions, including

Change Date

 June 14, 2019

V.iii.7.3.a.BPH

 Benign prostatic hypertrophy (BPH) is evaluated under 38 CFR 4.115b, DC 7527 based on associated voiding dysfunction or urinary tract infection, but can be evaluated as renal dysfunction 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.

V.iii.7.3.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.  An assessment should, however, be based on more than PSA results such as, but not limited to, other clinical findings, reports of symptoms, or other medical evidence

V.iii.7.3.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.
Note:  If watchful waiting is used to closely monitor inactive cancer that is in remission, evaluate based on residuals since the cancer is no longer active.
Radical prostatectomy surgery which
  • is characterized by removal of the 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, and
  • 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, and
  • 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

V.iii.7.3.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 V, Subpart iii, 7.3.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 V, Subpart iii, 7.4.b.

4.ED

Introduction

 This topic contains information about ED, including

Change Date

 November 15, 2021

V.iii.7.4.a.ED

 ED is evaluated with a noncompensable evaluation under 38 CFR 4.115b, DC 7522 without regard to whether penile deformity is present. Reference:  For more information on evaluating deformity of the penis under the version of the rating schedule in effect prior to November 14, 2021, see Williams v. Wilkie, 30 Vet.App. 134 (2018).

V.iii.7.4.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

V.iii.7.4.c.ED Associated With Systemic Disease

 When evaluating residuals of a systemic disease process such as multiple sclerosis or amyotrophic lateral sclerosis and associated ED, award SC for ED and assign a separate evaluation for the ED when it is otherwise appropriate to separately evaluate residuals. Exception:  Noncompensable complications of diabetes mellitus must be evaluated with the disease process as provided in 38 CFR 4.119, DC 7913. Reference:  For more information on the assignment of a separate evaluation for ED associated with systemic disease processes, see M21-1, Part V, Subpart iii, 12.C.

V.iii.7.4.d.Scars Associated With ED

 Evaluations for ED assigned under 38 CFR 4.115b, DC 7522 account for the functional impairment arising from disease or traumatic injury.  Evaluation under this DC does not preclude a separate evaluation for non-functional impairment, such as painful scarring, under 38 CFR 4.118 when otherwise warranted.

5.Other Genitourinary Considerations

Introduction

 This topic contains information about other genitourinary considerations, including

Change Date

 November 15, 2021

V.iii.7.5.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

V.iii.7.5.b.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

V.iii.7.5.c.Hydrocele and Varicocele

 Hydrocele is a collection of fluid in the scrotum. Varicocele is a dilatation of the veins along the cord that receives blood from the testicles. These conditions may be associated with a decrease in fertility and, in rare instances, may be associated with infertility.  In instances where there is a clinical finding of infertility which is linked to the hydrocele or varicocele, entitlement to SMC is warranted.