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Dear Editor: Diverticulosis is a very common colonic pathology occurring in more than 65% of the population by the age of 80. The inflammatory process involving diverticulosis arises with an inflammatory response that may require surgery for hemorrhage, abscess, perforation, or fistula formation. The pathophysiology of colouterine fistulas includes destruction of two serosas of two epithelialized surfaces in close proximity. We describe the case of an elderly 76-year-old patient who presented within a period of 6 months with two episodes of acute diverticulitis that required endovenous treatment. The patient had already presented with fecal incontinence. At this time, the patient was taken to the emergency room because of the presence of a foul-smelling vaginal discharge with fecaloid flow. Abdominal examination revealed a low tenderness in the left lower quadrant, without palpable mass. The patient had no fever. Laboratory tests did not show any alteration in biological values. Antibiotic treatment was initiated and the patient was studied. A CT scan was performed that showed the presence of a uterus full of air and fecal content. Also, an inflammatory sigmoid colon with the presence of diverticles and a thick sigmoid wall could be seen. An image of malignancy could not be excluded. All these data confirmed the presence of a colouterine fistula. No colonoscopy had been yet performed because of the wish of the patient and their family. Surgery was performed and, at laparotomy, a chronic inflammatory mass was observed. This mass included the whole sigmoid colon and the posterior uterine wall. An en bloc resection was performed with a Hartman’s procedure. Colouterine fistulas were first reported by Lejemtel in 1909. At that time, three main etiologies were described: first, trauma or spontaneous rupture of a gravid uterus in which an intestinal loop impacted on the tear and a subsequent necrosis developed after constricting contractions of the myometrium; second, the presence of abscess rupture into the bowel and the uterus; third, a uterine or sigmoid carcinoma. In later years, radiotherapy has also been involved in colouterine fistula formation. Hawkes described obstetric trauma including curettage of the uterus with simultaneous perforation of the uterus and the colon. The first report of colouterine fistulas related to diverticulitis was by Noecker in 1929. This diagnosis is rare and even rarer is to observe colouterine fistulas related to diverticulitis. Among causes other than diverticulitis, endometriosis, gynecological cancer, and also apex abscesses have been described. Many reasons have been provided in order to explain colouterine fistula formation. Owing to the great thickness of the uterine wall, colouterine fistulas are very rare. The development of diverticulitis episodes may lead to a fistula formation, because of repeated inflammatory response in the tissues, such as in our patient. Repeated acute episodes of diverticulitis may lead to adhesions, local inflammation, with subsequent necrosis and fistula formation. It is usually the fundus of the uterus and the sigmoid colon that are linked. Also, a perforated sigmoid colon in the presence of an abscess may be the cause of the fistula formation, which was the case with our patient. Int J Colorectal Dis (2009) 24:599–600 DOI 10.1007/s00384-008-0630-x