A 15-year-old Appendix Quarter Horse gelding presented to Cornell Equine Nemo Farm Animal Hospital (ENFAH) Emergency Services with a one-day history of dysuria and discomfort. Diagnostics performed, including point of care blood work, abdominal ultrasound, and urethroscopy, identified a left nephrolith and an obstructive urethrolith. Perineal urethrostomy was performed standing and the urethrolith, presumptively calcium carbonate, was removed. Cystoscopy revealed an obstructed left ureter, presumptively caused by a ureterolith. During his three-day hospitalization, the patient was treated with trimethoprim sulfamethoxazole and topical management of his hind end to prevent urine scald. He was discharged with creatinine levels at the high end of the normal range. Recheck examinations in the following two weeks revealed healing of his perineal urethrotomy site and relatively unchanged creatinine levels. This paper will focus on equine uroliths, surgical options for obstructive uroliths, and medical management of uroliths.