The term “urban stream syndrome” describes the consistently observed ecological degradation of streams draining urban land. This paper reviews recent literature to describe symptoms of the syndrome, explores mechanisms driving the syndrome, and identifies appropriate goals and methods for ecological restoration of urban streams. Symptoms of the urban stream syndrome include a flashier hydrograph, elevated concentrations of nutrients and contaminants, altered channel morphology, and reduced biotic richness, with increased dominance of tolerant species. More research is needed before generalizations can be made about urban effects on stream ecosystem processes, but reduced nutrient uptake has been consistently reported. The mechanisms driving the syndrome are complex and interactive, but most impacts can be ascribed to a few major large-scale sources, primarily urban stormwater runoff delivered to streams by hydraulically efficient drainage systems. Other stressors, such as combined or sanitary sewer overflows, wastewater treatment plant effluents, and legacy pollutants (long-lived pollutants from earlier land uses) can obscure the effects of stormwater runoff. Most research on urban impacts to streams has concentrated on correlations between instream ecological metrics and total catchment imperviousness. Recent research shows that some of the variance in such relationships can be explained by the distance between the stream reach and urban land, or by the hydraulic efficiency of stormwater drainage. The mechanisms behind such patterns require experimentation at the catchment scale to identify the best management approaches to conservation and restoration of streams in urban catchments. Remediation of stormwater impacts is most likely to be achieved through widespread application of innovative approaches to drainage design. Because humans dominate urban ecosystems, research on urban stream ecology will require a broadening of stream ecological research to integrate with social, behavioral, and economic research.