Coastal wetlands perform a unique set of physical, chemical, and biological functions, which provide billions of dollars of ecosystem services annually. These wetlands also face myriad environmental and anthropogenic pressures, which threaten their ecological condition and undermine their capacity to provide these services. Coastal wetlands have adapted to a dynamic range of natural disturbances over recent millennia, but face growing pressures from human population growth and coastal development. These anthropogenic pressures are driving saltwater intru sion (SWI) in many coastal systems. The position of coastal wetlands at the terrestrial-marine interface also makes them vulnerable to increasing rates of sea level rise and changing climate. Critically, anthropogenic and natural stressors to coastal wetlands can act synergistically to create negative, and sometimes catastrophic, consequences for both human and natural systems. This review focused on the drivers and impacts of SWI in coastal wetlands and has two goals: (1) to synthesize understanding of coastal wetland change driven by SWI and (2) to review approaches for improved water management to mitigate SWI in impacted systems. While we frame this review as a choice between restoration and retreat, we acknowledge that choices about coastal wetland management are context-specific and may be confounded by competing management goals. In this setting, the choice between restoration and retreat can be prioritized by identifying where the greatest return in ecosystem services can be achieved relative to restoration dollars invested. We conclude that restoration and proactive water management is feasible in many impacted systems.