Incidence of nephrolithiasis has increased dramatically over the past 30 years, likely due to environmental changes such as dietary habits. Nephrolithiasis presents as acute flank or abdominal pain with nausea and vomiting. Hematuria is present in 90% of cases, but its absence does not rule out nephrolithiasis. Most cases can be managed expectantly as an outpatient with hydration, analgesia, and possibly medications to aide in passage. A metabolic evaluation may be indicated after a second episode of nephrolithiasis in adults or after a first episode in children or those with a family history of nephrolithiasis.