Vesicoureteral reflux is seen in up to one half of all children with urinary tract infections and reflux nephropathy is potentially the leading reversible cause of end-stage renal disease in children and adults. Recent studies still leave some doubt to the pathogenesis of reflux nephropathy. In 1992, the International Reflux Study in Children published data on the 5-year follow-up of children with high-grade reflux showing no clear advantage toward either surgical or medical management (although new surgical techniques may prove beneficial). A need to identify children with dysfunctional voiding exists. Appropriate, preferably noninvasive, studies should be employed to identify children at risk including those with antenatally diagnosed hydronephrosis and siblings of children with documented reflux.