Object Pituitary incidentalomas are a common finding with a poorly understood natural history. Over the last few decades, numerous studies have sought to decipher the optimal evaluation and treatment of these lesions. This paper aims to elucidate the current evidence regarding their prevalence, natural history, evaluation, and management. Methods A search of articles on PubMed (National Library of Medicine) and reference lists of all relevant articles was conducted to identify all studies pertaining to the incidence, natural history, workup, treatment, and follow-up of incidental pituitary and sellar lesions, nonfunctioning pituitary adenomas, and incidentalomas. Results The reported prevalence of pituitary incidentalomas has increased significantly in recent years. A complete history, physical, and endocrinological workup with formal visual field testing in the event of optic apparatus involvement constitutes the basics of the initial evaluation. Although data regarding the natural history of pituitary incidentalomas remain sparse, they seem to suggest that progression to pituitary apoplexy (0.6/100 patient-years), visual field deficits (0.6/100 patient-years), and endocrine dysfunction (0.8/100 patient-years) remains low. In larger lesions, apoplexy risk may be higher. Conclusions While the majority of pituitary incidentalomas can be managed conservatively, involvement of the optic apparatus, endocrine dysfunction, ophthalmological symptoms, and progressive increase in size represent the main indications for surgery.