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Summary Introduction/Objective The dynamic hydrodistention (HD) classification is a basic and objective way of rating the ureteral orifice opening. This study evaluated the value of hydrodistention of the ureteral orifice in the diagnosis of vesicoureteral reflux (VUR). Material and methods Between January 2012 and March 2013 the HD grade in 106 ureters was prospectively assigned. A 9.5-Fr rigid cystoscope with a 0-degree lens was used in all procedures. Warm saline was used and the irrigation bag was placed approximately 1 m above the bladder level on full flow. The grading is as follows: H0 denotes absence of ureteral dilation; H1 indicates dilation of the ureteral orifice only; H2 allows visualization of the intramural ureter; and H3 allows visualization of the extramural ureter. Indications for cystoscopy were endoscopic and open surgical treatment of VUR, stent removal, and any other diagnostic reasons. Exclusion criteria were patients with: infravesical obstruction, neuropathic bladder, severe detrusor over activity/dysfunctional voiding, duplex system, paraureteral diverticulum, bladder exstrophy and grade-1 VUR. The 51 refluxing ureters (RUs) were compared with 55 non-refluxing ureters (NRUs). Finally, sensitivity, specificity, positive and negative predictive values, and accuracy rate of HD were evaluated. Results A total of 106 ureters in 61 patients with a mean age of 5.3 ± 3.9 years (range 2 months–15 years, median 5 years) were prospectively assigned. The mean HD grade in the RUs was 2.17 ± 0.55. The mean HD grades were 2.0 ± 0.63, 2.07 ± 0.53, 2.38 ± 0.5 and 2.5 ± 0.57 for VUR grades 2–5, respectively. The mean HD grade in the NRUs was 1.60 ± 0.70. The HD grades were H0 to H3 in 7.3%, 30.9%, 56.4% and 5.4% of the NRUs, respectively. The RUs group (2.17 ± 0.55) showed a statistically higher HD grade than the NRUs group (1.60 ± 0.70) ( P < 0.005). Sensitivity, specificity, positive and negative predictive values, and accuracy rate of HD grading in the diagnosis of VUR were 92%, 38%, 58%, 84%, and 64%, respectively. The mean HD grade in contralateral ureters of unilateral VUR was 1.55 ± 0.72 and HD grades were H0–H3 in 0%, 55.6%, 33.3% and 11.1% of these nine ureters, respectively. In these nine non-refluxing contralateral ureters, after endoscopic correction of ipsilateral VUR, new contralateral VUR did not occur. Conclusion Even though HD grade was high in the VUR group and popularity of the HD grading is on the increase, HD grading by itself still has a low diagnostic value. [ABSTRACT FROM AUTHOR]