In each urolithiasis patient the individual risk for recurrence determines the need for specific medical treatment. Therefore, a brief evaluation of the risk status after stone passage is mandatory to define patients at high risk for recurrence. Only one quarter of all urolithiasis patients are at high risk or suffer from severe metabolic disorders, which both demand further metabolic work-up prior to medical therapy. However, the other three quarters benefit sufficiently from general preventive measures, such as high fluid intake, well-balanced mixed diet and lifestyle changes. This article summarizes the recent recommendations for stone-specific recurrence prevention, discusses the different pharmacological treatment options and sketches the follow-up concept for high risk patients with ongoing medication.