Evidence is accumulating that in the large majority of infants and children with vesicoureteral reflux, the bladder is the culprit. The same mechanisms that create reflux in the neurogenic bladder (outflow obstruction due to poor cooperation between detrusor and sphincters, and detrusor hyperactivity) also seem to operate in non-neuropathic bladders, in the fetus, neonate and older child. The lesson to be learned is that, in addition to chemoprophylaxis, treatment for the dysfunctional bladder should be attempted before considering reimplantation. In many infants and children with bilateral reflux the ureterovesical junction may have sustained irreversible damage during fetal development so that reflux persists indefinitely. As yet, however, there are no hard facts available to help us determine whether persisting reflux in an adolescent should be operated on or not. Reflux nephropathy is a largely preventable complication of reflux. It is of the outmost importance to start chemoprophylaxis without delay and to rule out reflux in two categories of newborns who are at extreme risk for renal damage caused by postnatal pyelonephritis: those who belong to reflux families, and those who had an antenatally detected hydronephrosis. A clinical programme for the prevention of reflux nephropathy is presented.
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