Urolithiasis patients are facing a life time recurrence risk making metabolic considerations, repeat imaging and possible interventions necessary. A thorough medical history is important including various diseases like hyperparathyroidism, gastrointestinal diseases like Crohn’s disease, previous bariatric surgery, enteric hyperoxaluria following urinary diversion or sarcoidosis as well as the family history, laboratory findings, and stone analysis. Laboratory examinations depend on the clinical situation however should cover the actual needs at the moment as well as a “screening” for an underlying metabolic disorder. Urinalysis must include urinary pH, rule out possible urinary infections, and support metabolic evaluations. Imaging—after initial ultrasound (US)—is different depending on whether a stone in the ureter is suspected or a kidney stone. In acute situations a ureteral stone might be ruled out with US followed if applicable by KUB (kidney-ureter-bladder X-ray); if unclear, a (low dose) NCCT (non-contrast computerized tomogram) can detect almost all kinds of relevant stones except some rare drug-induced (indinavir) or matrix stones. With renal stones, however, objectives of imaging differ; this may require a contrast study; enhanced CT or intravenous pyelogram offer different advantages and disadvantages depending on the clinical questions. Acute management of renal colic must not be delayed. Nonsteroidal anti-inflammatory drugs (NSAIDs) (including dipyrone (metamizol)), and paracetamol are the first choice for pain control. Fever and obstruction or anuria by itself are urological emergencies usually needing urgent decompression of collecting system besides other measures. All examinations and medications must consider contraindications and weight X-ray exposure.