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

Model Number	50050
Medical Device Problem Code	Adverse Event Without Identified Device or Use Problem (2993)
Health Effect - Clinical Codes	Incontinence (1928); Rash (2033)
Date of Event	12/11/2024
Type of Reportable Event	Serious Injury
Event or Problem Description
The patient was prescribed medication due to a rash.

• Brand Name: AXONICS
• Common Device Name: AGENT, BULKING, INJECTABLE FOR GASTRO-UROLOGY USE
• Manufacturer (Section D): AXONICS, INC; 15515 sand canyon ave; irvine CA 92618
• Manufacturer (Section G): CONTURA INTERNATIONAL A/S; 23 sydmarken; soeborg 2860 ; DK 2860
• Manufacturer Contact: linda phan ; 15515 sand canyon ave; irvine, CA 92618
• MDR Report Key: 21087927
• Report Number: 3002968685-2025-00006
• Device Sequence Number: 12491819
• Product Code: LNM
• UDI-Device Identifier: 10810005340509
• UDI-Public: 10810005340509
• Combination Product (Y/N): N
• Initial Reporter State: NC
• Initial Reporter Country: US
• PMA/510(K) Number: P170023
• Number of Events Summarized: 1
• Summary Report (Y/N): N
• Serviced by Third Party (Y/N): N
• Reporter Type: Manufacturer
• Report Source: Company Representative
• Initial Reporter Occupation: Physician
• Type of Report: Initial
• Report Date (Section B): 01/06/2025

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
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Type of Report(Section G): Thirty-Day
• Initial Date Received by Manufacturer: 12/11/2024
• Initial Report FDA Received Date: 01/06/2025
• Was Device Evaluated by Manufacturer? (Y/N): No
• 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