We report the thirteenth case of a rectourethral fistula in Crohn's disease. The patient, a 37 year-old-white male, had a 20 year history of intestinal Crohn's disease and had undergone numerous bowel resections. His symptoms were fecaluria, urorrhea and passing of urine from an orifice just outside the base of the scrotum. He had urinary infection and severe ileocolitis. He underwent a diagnostic evaluation that revealed a fistula comprising the membranous urethra, the rectum, the perineum and the scrotum. We performed medical therapy with metronidazole (20 mg/kg/day/12 months). We present in this article a review of the literature on the management of rectourethral fistulas in Crohn's disease. Surgeons have successfully used several approaches in the repair of this disorder, but no single procedure had proved to be best or even universally applicable. We emphasize, as the literature suggests, that management must be individualized. Medical therapy with metronidazole has an important role in a patient with rectourethral fistula and concomitant proctitis, ileocolitis, urinary sepsis and multiple previous surgeries.