Gouty arthritis is the most common form of arthritis in men. As a consequence of persisting hyperuricemia, uric acid crystals are deposited in the intra-articular and periarticular spaces and activate the innate immune system. The clinically impressive abrupt onset monoarticular arthritis in the lower extremities is highly suggestive of a gout attack. Arthrosonography can be used for early detection of crystal deposition on joint cartilage. In synovial fluid the detection of uric acid crystals in polarization microscopy is proof of gout even without the detection of intracellular uric acid crystals. Rapidly acting anti-inflammatory drugs are available for acute treatment of attacks; however, the essential therapy is the effective and life-long drug treatment of hyperuricemia from the first attack onwards, typically with allopurinol or febuxostat. This review delineates the clinically relevant knowledge on the pathogenesis, diagnosis and therapy of gout based on the currently available evidence.