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Freshwater systems, including urban streams and groundwater, are increasingly affected by climate change through altered precipitation, rising temperatures, droughts, floods, and changing water demand. This narrative review synthesizes evidence on how these pressures modify groundwater–stream connectivity and the resulting ecological, conservation, and sustainability implications in urban environments. The literature shows that groundwater supports baseflow, thermal buffering, hyporheic exchange, and habitat persistence, but that urbanization can simultaneously reduce natural recharge and create new anthropogenic recharge pathways. Studies of urban streams document flashier hydrographs and ecological degradation under conventional urbanization, whereas infiltration-focused low-impact development has been shown in some catchments to increase baseflow and reduce seasonal variability. Climate change adds further pressure: global modelling projects substantial warming of shallow groundwater by 2100, while long-term stream studies show taxon-specific community responses to warming and extreme events. Major knowledge gaps include limited long-term paired groundwater–stream observations, scale mismatches among hydrology, ecology, and governance, and underrepresentation of arid, semi-arid, tropical, and Global South cities. Addressing these gaps requires coupled hydrological–ecological research, functional indicators, and context-specific nature-based and hybrid management strategies that maintain or restore groundwater–stream connectivity as a component of urban freshwater resilience.