MAUDE Adverse Event Report: LENA CUP LENA CUP; MENSUTRAL CUP

Model Number	LENA-PUR-S
Health Effect - Clinical Code	No Clinical Signs, Symptoms or Conditions (4582)
Date of Event	05/01/2021
Type of Reportable Event	Serious Injury
Event or Problem Description
Unable to remove menstrual cup, she sought medical intervention to help remove it.

• Brand Name: LENA CUP
• Common Device Name: MENSUTRAL CUP
• Manufacturer (Section D): LENA CUP; 3540 highway 52; suite h12; frederick CO 80516
• MDR Report Key: 12009333
• Report Number: 3011390-2021-00011
• Device Sequence Number: 16487602
• Product Code: HHE
• UDI-Device Identifier: 00850008236075
• UDI-Public: 00850008236075
• Combination Product (Y/N): N
• Initial Reporter Country: US
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): Unknown
• Reporter Type: Manufacturer
• Report Source: consumer
• Initial Reporter Occupation: Other
• Type of Report: Initial
• Report Date (Section B): 06/14/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: No
• Operator of Device: Lay User/Patient
• Device Model Number: LENA-PUR-S
• Device Catalogue Number: LENA-PUR-S
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 05/21/2021
• Initial Report FDA Received Date: 06/16/2021
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Patient Sequence Number: 1