Chapter 16 - Urinary, Sexual, Reproductive and Breast Impairment

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Table of Contents PDF Version

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Introduction

This chapter provides criteria for assessing permanent impairment from entitled urinary, sexual, reproductive and breast conditions.

The chapter is divided into two sections. The first section provides criteria to rate impairment of upper and lower urinary tract conditions. The second section provides criteria to rate impairment of sexual, reproductive and breast conditions.

Impairment from rectovaginal fistula(e) is rated within Chapter 14, Gastrointestinal Impairment.

Impairment from loss of a kidney due to tuberculosis is rated within Chapter 24, Tuberculosis Impairment.

Impairment from malignant urinary, sexual, reproductive and breast conditions is rated within Chapter 18, Malignant Impairment. Follow the steps contained within the Malignant Impairment chapter.

For the purposes of this chapter:

Female: means cis female, a person assigned female sex at birth and identifies as a woman.

Male: means cis male, a person assigned male sex at birth and identifies as a man.

Sex/gender diverse: means a person with differences in sexual development, people who do not identify within the binary terms of sex and/or gender as a man or a woman, and people who identify as transgender.

An individual’s present anatomy is used to select the applicable impairment table(s). This includes sex/gender diverse individuals who have not yet undertaken gender affirming treatment (hormone and/or surgery).

For sex/gender diverse individuals who have undertaken gender affirming treatment (hormone and/or surgery), the medical impairment rating is determined based on individual merit.

Penetrative sexual activity is defined as the insertion of a body part or other object into the mouth, vagina or anus, as part of human sexual activity.

Sexual activity is defined as the manner in which humans experience and express their sexuality.

Rating Tables

This chapter contains four “Loss of Function” tables and two “Other Impairment” tables which may be used to rate entitled urinary, sexual, reproductive and breast conditions.

The tables within this chapter are:

The tables within this chapter are:

Table 16.1	Loss of Function - Upper Urinary Tract	This table is used to rate impairment in the upper urinary tract.
Table 16.2	Loss of Function - Lower Urinary Tract	This table is used to rate impairment in the lower urinary tract.
Table 16.3	Loss of Function - Sexual and Reproductive - Male Anatomy	This table is used to rate impairment in sexual and reproductive function in male anatomy.
Table 16.4	Loss of Function - Sexual and Reproductive - Female Anatomy	This table is used to rate impairment in sexual and reproductive function in female anatomy.
Table 16.5	Other Impairment - Breasts - Male Anatomy	This table is used to rate impairment of the male breast.
Table 16.6	Other Impairment - Breasts - Female Anatomy	This table is used to rate impairment of the female breast.

Section 1

Determining Impairment Assessment of Urinary Tract Function

The tables that may be used to rate impairment from urinary tract conditions are:

The tables that may be used to rate impairment from urinary tract conditions are:

Table 16.1	Loss of Function - Upper Urinary Tract	This table is used to rate impairment in the upper urinary tract.
Table 16.2	Loss of Function - Lower Urinary Tract	This table is used to rate impairment in the lower urinary tract.

Loss of Function - Upper Urinary Tract

Table 16.1 is used to rate impairment from conditions of the upper urinary tract (kidney and ureter). Only one rating may be selected for each entitled condition. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest selected.

Ratings in the upper urinary tract table take into account the presence of signs and symptoms and laboratory findings which may accompany the urinary tract impairment. Signs and symptoms may include hypertension, chronic anemia, edema, headache, dyspnea, fatigue, fever, chills, back pain, dizziness, hematuria, anuria and recurrent upper urinary tract infections.

Glomerular Filtration Rate(GFR) is the best indicator of overall kidney function. Estimation of GFR (eGFR) using an equation remains the accepted and most practical means of assessing kidney function. The current “gold standard” equation for eGFR is the CKD-EPI Equation^Footnote1 (Chronic Kidney Disease Epidemiology Collaboration Equation).

When entitled upper urinary tract conditions result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

Loss of or impairment of function of a second kidney may result in a paired organ award. In such cases, refer to chapter 4 - Paired Organs and Paired Limbs for assessment purposes.

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Loss of Function - Lower Urinary Tract

Table 16.2 is used to rate impairment from conditions of the lower urinary tract (bladder and urethra), prostate and epididymis. Only one rating may be selected for each entitled condition. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest selected.

When entitled lower urinary tract conditions result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Table 16.1 - Loss of Function - Upper Urinary Tract

Only one rating may be given for each entitled condition from Table 16.1. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest rating is selected.

Each bullet (•) represents one criterion. In order for a rating to be established for Table 16.1, follow the “ands” and “ors”.

Table 16.1 - Loss of Function - Upper Urinary Tract

Rating	Criteria
Nil	Normal or mildly impaired renal function; and No clinical signs of renal disease.
Four	Pyelonephritis: up to 2 attacks per year; or Kidney stones: occasional attacks of renal colic. Normal GFR but requires ongoing renal monitoring.
Nine	Diminution in renal function evidenced by GFR of 60-89*. Signs and symptoms and abnormal laboratory findings may be present; or Pyelonephritis: 3 - 4 attacks per year; or Kidney stones: yearly attacks of renal colic; or Chronic unilateral hydronephrosis with infection.
Thirteen	Pyelonephritis: more than 4 attacks per year; or Nephrectomy; or Chronic bilateral hydronephrosis with infection.
Twenty-one	Successful renal transplant (minimum rating).
Twenty-six	Diminution in renal function evidenced by GFR of 45-59*. Signs and symptoms and abnormal laboratory findings may be present; or Permanent urinary diversion with ostomy of the skin (i.e. nephrostomy, ureterointestinal, ileal conduit, cutaneous ureterostomy).
Forty-three	Diminution in renal function evidenced by GFR of 30-44. Signs and symptoms and abnormal laboratory findings may be present.
Fifty-seven	Diminution in renal function evidenced by GFR of 15-29*. Signs and symptoms and abnormal laboratory findings may be present.
Eighty-one	Diminution in renal function evidenced by GFR of less than 15*. Signs and symptoms and abnormal laboratory findings may be present; or Requiring ongoing peritoneal or hemodialysis.

*GFR units of measurement are mL/min/1.73 m². A GFR>60mL/min/1.73 m² in isolation is not CKD, unless other evidence of kidney damage is present. CKD, chronic kidney disease; GFR, glomerular filtration rate.

Steps to Determine Urinary Tract Assessment (Upper Tract)

• Step 1: Determine the rating from Table 16.1 (Loss of Function - Upper Urinary Tract).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to the rating above.

This is the Disability Assessment.

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Table 16.2 - Loss of Function - Lower Urinary Tract

Only one rating may be given for each entitled condition from Table 16.2. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest selected.

Each bullet (•) represents one criterion. In order for a rating to be established for Table 16.2, only one criterion must be met at a level of impairment for that rating to be selected.

Table 16.2 - Loss of Function - Lower Urinary Tract

Rating	Criteria
Nil	Voiding dysfunction: occasional symptoms of dysuria, urgency or frequency; or Prostatectomy.
One	Obstructed voiding: with hesitancy or diminished stream; or Lower urinary tract infection: occurring 1-2 times per year.
Four	Voiding dysfunction: symptoms of dysuria, urgency and/or frequency; daytime voiding every 3 hours and awakening once through the night; or 1 - 2 incontinent pads required daily; or Chronic epididymitis without urinary tract symptoms but with ongoing pain.
Nine	Obstructed voiding: requiring 2 - 4 dilatations per year; or Lower tract infection: occurring at least 4 times per year despite long term prophylactic antibiotic drug therapy.
Thirteen	Voiding dysfunction: symptoms of dysuria, urgency and frequency; daytime voiding every 2 hours and nocturia 2 - 3 times per night; or More than 2 incontinent pads required daily.
Eighteen	Voiding dysfunction: symptoms of dysuria, urgency and frequency; daytime voiding every 1 hour and nocturia 4 - 5 times per night; or Permanent use of condom catheter; or Obstructed voiding: with any one of the following: post-void residuals greater than 150 cc; uroflowmetry - markedly diminished peak flow rate (less than10 cc/sec); stricture disease requiring more than 4 dilatations per year.
Twenty-six	Voiding dysfunction: symptoms of dysuria, urgency and frequency, with less than 30 minutes between voidings and voiding more than 5 times per night; or Obstructed voiding: with urinary retention requiring intermittent daily catheterization.
Thirty-four	Voiding dysfunction: no voluntary control of bladder; or Permanent indwelling catheter.
Forty-three	Voiding dysfunction: with painful urinary frequency and voids every 15 minutes day and night; or Permanent suprapubic catheter.

Steps to Determine Urinary Tract Assessment (Lower Tract)

• Step 1: Determine the rating from Table 16.2 (Loss of Function - Lower Urinary Tract).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to the Step 4 rating.

This is the Disability Assessment

Section 2

Determining Impairment Assessment of Sexual, Reproductive and Breast Function

Selection of Tables

The tables that may be used to rate impairment from sexual and reproductive conditions are:

The tables that may be used to rate impairment from sexual and reproductive conditions are:

Table 16.3	Loss of Function - Sexual and Reproductive - Male Anatomy	This table is used to rate impairment in sexual and reproductive function in male anatomy.
Table 16.4	Loss of Function - Sexual and Reproductive - Female Anatomy	This table is used to rate impairment in sexual and reproductive function in female anatomy.
Table 16.5	Other Impairment - Breasts - Male Anatomy	This table is used to rate impairment of the male breast.
Table 16.6	Other Impairment - Breasts - Female Anatomy	This table is used to rate impairment of the female breast.

Loss of Function - Sexual and Reproductive - Male Anatomy

Table 16.3 is used to rate impairment from sexual and reproductive conditions impacting male anatomy.

Only one rating may be selected for each entitled condition. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest selected.

For Veterans Affairs Canada (VAC) purposes ‘Sterility’ is defined as the complete inability to produce offspring despite medical intervention.

‘Infertility’ is defined as inability to conceive after one year or longer of unprotected sex. For VAC purposes where an entitled condition results in infertility, it will be assessed on individual merits.

When entitled sexual and reproductive conditions impacting male anatomy result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Loss of Function - Sexual and Reproductive - Female Anatomy

Table 16.4 is used to rate impairment from impairment from sexual and reproductive conditions impacting female anatomy.

Only one rating may be selected for each entitled condition. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest selected.

For VAC purposes ‘Sterility’ is defined as the complete inability to produce offspring despite medical intervention.

‘Infertility’ is defined as inability to conceive after one year or longer of unprotected sex. For VAC purposes where an entitled condition results in infertility, it will be assessed on individual merits.

When entitled sexual and reproductive conditions impacting female anatomy result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Other Impairment - Breasts - Male Anatomy

Table 16.5 is used to rate impairment from male breast conditions. Only one rating may be selected for each entitled condition. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest selected.

When entitled male breast conditions result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Other Impairment - Breasts - Female Anatomy

Table 16.6 is used to rate impairment from female breast conditions. Only one rating may be selected for each entitled condition. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest selected.

When entitled female breast conditions result in permanent impairment of other organ systems, a consequential entitlement decision is required. If awarded, the resulting impairment of that organ system(s) will be rated using the applicable body system specific table(s).

If non-entitled conditions or conditions rated within another chapter/table of the Table of Disabilities are contributing to the overall impairment, then the Partially Contributing Table (PCT) must be applied to arrive at the rating which is due to the entitled condition(s) rated within this table.

Table 16.3 - Loss of Function - Sexual and Reproductive - Male Anatomy

Only one rating may be given for each entitled condition from Table 16.3. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest selected.

Each bullet (•) represents one criterion. In order for a rating to be established for Table 16.3, only one criterion must be met at a level of impairment for that rating to be selected.

Table 16.3 - Loss of Function - Sexual and Reproductive - Male Anatomy

Rating	Criteria
Nil	Circumcision; or Varicocele, hydrocele or spermatocele asymptomatic; or Vasectomy* or Erectile Dysfunction not requiring treatment.
One	Unilateral or bilateral atrophy of the testicle(s)/external gonad(s); or Sexual aversion or arousal disturbance without avoidance of sexual activity.
Four	Loss of one testicle/external gonad (Orchiectomy); or Peyronie’s disease; still capable of penetrative sexual activity; or Varicocele, hydrocele or spermatocele symptomatic; or Erectile dysfunction treated with medications and/or counselling; or Difficulty with ejaculation; or Ejaculatory pain, and able to participate in penetrative sexual activity; or Sexual aversion or arousal disturbance with occasional avoidance of sexual activity.
Nine	Permanent sterility; or Complete inability to achieve ejaculation*; or Erectile dysfunction treated with intrathecal injection, pumps and/or prothesis; or Genital pain with some response to treatment.
Eighteen	Ejaculatory pain with inability to participate in penetrative sexual activity; or Peyronie’s disease; incapable of penetrative sexual activity; or Erectile dysfunction unresponsive to all treatment*; or Loss of up to one-half of the penis*; or Sexual aversion or arousal disturbance resulting in complete avoidance of sexual activity.
Twenty-six	Loss of more than one-half of the penis*; or Bilateral loss of testicles/external gonads*; or Genital pain, severe, persistent, and unresponsive to treatment.

* A separate rating for permanent sterility is not given for these conditions.

Steps to Determine Sexual and Reproductive Assessment (Male Anatomy)

• Step 1: Determine the rating from Table 16.3 (Loss of Function - Sexual and Reproductive - Male Anatomy).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to the rating at Step 4.

This is the Disability Assessment.

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Table 16.4 Loss of Function - Sexual and Reproductive - Female Anatomy

Only one rating may be given for each entitled condition from Table 16.4. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest selected.

Each bullet (•) represents one criterion. In order for a rating to be established for Table 16.4, only one criterion must be met at a level of impairment for that rating to be selected.

Table 16.4 - Loss of Function - Sexual and Reproductive - Female Anatomy

Rating	Criteria
Nil	Tubal ligation*; or Permanent sterility; onset at or after natural menopause; or Hysterectomy*; post-menopausal; or Unilateral loss of tubal patency.
One	Dysmenorrhea; or Sexual aversion or arousal disturbance without avoidance of sexual activity.
Four	Loss of one ovary/internal gonad (oophorectomy); premenopausal; or Heavy bleeding (menorrhagia) and/or irregular bleeding (metrorrhagia) responsive to treatment; or Difficulty in achieving orgasm*; or Vaginal penetration pain and able to participate in vaginal penetrative sexual activity; or Sexual aversion or arousal disturbance with occasional avoidance of sexual activity.
Nine	Genito-pelvic pain and/or heavy irregular bleeding requiring continuous treatment to control; or Permanent sterility; premenopausal; or Bilateral loss of tubal patency*; premenopausal; or Bilateral salpingectomy* (not carried out for contraceptive purposes); premenopausal; or Hysterectomy*; premenopausal; or Complete inability to achieve orgasm*.
Eighteen	Vaginal penetration pain with inability to participate in vaginal penetrative sexual activity; or Sexual aversion or arousal disturbance resulting in complete avoidance of sexual activity.
Twenty-six	Vulvectomy; or Clitoridectomy; or Loss of both ovaries/internal gonads*; premenopausal; or Severe vaginal stenosis; or Genito-pelvic pain (e.g., endometriosis or other causes), severe, persistent, and unresponsive to treatment.

* A separate rating for permanent sterility is not given for these conditions.

Steps to Determine Sexual and Reproductive Assessment (Female Anatomy)

• Step 1: Determine the rating from Table 16.4 (Loss of Function - Sexual and Reproductive - Female Anatomy)
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to the rating at Step 4.

This is the Disability Assessment.

Table 16.5 - Other Impairment - Breasts - Male Anatomy

Only one rating may be given for each entitled condition from Table 16.5. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest selected.

Each bullet (•) represents one criterion. In order for a rating to be established for Table 16.5, only one criterion must be met at a level of impairment for that rating to be selected.

Table 16.5 - Other Impairment - Breasts - Male Anatomy

Rating	Criteria
Nil	Lumpectomy; or Gynaecomastia, operated.
One	Gynaecomastia not operated; or Unilateral mastectomy.
Four	Bilateral mastectomy; or Persistent mammary discharge.

Steps to Determine Assessment (Breasts - Male Anatomy)

• Step 1: Determine the rating from Table 16.5 (Other Impairment - Breasts - Male Anatomy).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to the rating at Step 4.

This is the Disability Assessment.

Table 16.6 - Other Impairment - Breasts - Female Anatomy

Only one rating may be given for each entitled condition from Table 16.6. If more than one rating is applicable for an entitled condition, the ratings are compared and the highest selected.

Each bullet (•) represents one criterion. In order for a rating to be established for Table 16.6, only one criterion must be met at a level of impairment for that rating to be selected.

Table 16.6 - Other Impairment - Breasts - Female Anatomy

Rating	Criteria
Nil	Lumpectomy.
Four	Partial unilateral mastectomy/segmental resection; or Unilateral mastectomy with reconstructive surgery; or Persistent mammary discharge.
Nine	Unilateral mastectomy without reconstructive surgery; or Bilateral mastectomy with reconstructive surgery.
Thirteen	Radical unilateral mastectomy; or Simple bilateral mastectomy without reconstructive surgery.
Twenty-six	Radical bilateral mastectomy without reconstruction.

Steps to Determine Assessment (Breasts - Female Anatomy)

• Step 1: Determine the rating from Table 16.6 (Other Impairment - Breasts - Female Anatomy).
• Step 2: Does the Partially Contributing Table apply? If yes, then apply to rating at Step 1.
• Step 3: Determine the Quality of Life rating.
• Step 4: Add the ratings at Step 2 and Step 3.
• Step 5: If partial entitlement exists, apply to the Step 4 rating.

This is the Disability Assessment.