MAUDE Adverse Event Report: AXONICS, INC BULKAMID URETHRAL BULKING SYSTEM; AGENT, BULKING, INJECTABLE FOR GASTRO-UROLOGY USE

Model Number	50050
Medical Device Problem Code	Unexpected Therapeutic Results (1631)
Health Effect - Clinical Code	Urinary Tract Infection (2120)
Date of Event	05/01/2023
Type of Reportable Event	Serious Injury
Event or Problem Description
The patient was treated with antibiotics for uti after a bulkamid procedure.
Event or Problem Description
See section h, number 6 for investigation updates.

• Brand Name: BULKAMID URETHRAL BULKING SYSTEM
• Common Device Name: AGENT, BULKING, INJECTABLE FOR GASTRO-UROLOGY USE
• Manufacturer (Section D): AXONICS, INC; 26 technology dr; irvine CA 92618
• Manufacturer (Section G): CONTURA INTERNATIONAL A/S; 23 sydmarken; soeborg
• Manufacturer Contact: linda phan ; 26 technology drive; irvine, CA 92618
• MDR Report Key: 17015105
• Report Number: 3002968685-2023-00071
• Device Sequence Number: 15345012
• Product Code: LNM
• UDI-Device Identifier: 05704101500500
• UDI-Public: 05704101500500
• Combination Product (Y/N): N
• Initial Reporter State: IL
• Initial Reporter Country: US
• PMA/510(K) Number: P170023
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Device Implanted Year: 2023
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial,Followup
• Report Date (Section B): 08/11/2023

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: Health Professional
• Device Model Number: 50050
• Device Lot Number: 22F1402AA
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Follow-Up
• Initial Date Received by Manufacturer: 05/03/2023
• Supplement Date Received by Manufacturer: 05/03/2023
• Initial Report FDA Received Date: 05/26/2023
• Supplement Report FDA Received Date: 08/11/2023
• Was Device Evaluated by Manufacturer? (Y/N): Device Not Returned to Manufacturer
• Is the Device Labeled for Single Use? (Y/N): Yes
• Is This a Single-Use Device that was Reprocessed and Reused on a Patient? (Y/N): No
• Usage of Device: Initial
• Patient Sequence Number: 1
• Patient Sex: Female