This paper reviews various impacts of urbanization on rivers and streams, which lead to symptoms summarized by the general term “urban stream syndrome”. Growing areas of impervious surfaces cause deterioration of water recipients flowing through urban areas. The symptoms of deterioration usually include altered chemical parameters of water and sediment, accumulation of priority pollutants in aquatic biota, changes in biological composition of the aquatic biota (lower biodiversity, changing abundance) and altered runoff regime of recipients (artificial floods versus extremely low flows). The paper concludes that restoration is the only way to achieve good ecological status (health) of the waterways. The restoration has to focus on measures to decrease the effective imperviousness and increase the retention and later local use of the water. The paper also highlights that effective management of urban streams includes social, economic, and political dimensions and requires a broader view beyond the traditional stream ecology.