Background <p>Pseudoepitheliomatous hyperplasia (PEH) is a benign reactive proliferation of squamous epithelium that can closely mimic squamous cell carcinoma (SCC) both clinically and histologically. PEH commonly arises in response to chronic irritation, infection, or trauma. Its occurrence in the prepuce is extremely rare and poses significant diagnostic challenges.</p> Case presentation <p>We report a case of a 75-year-old Indian male who presented with a 1-year history of progressive penile swelling, accompanied by obstructive voiding symptoms over recent weeks. Physical examination revealed a thickened, nodular, and edematous prepuce with phimosis, raising strong clinical suspicion of penile carcinoma. Incisional biopsy revealed features consistent with PEH, characterized by marked acanthosis, elongated and anastomosing rete ridges, and absence of cytological atypia. The patient subsequently underwent complete circumcision. Histopathological analysis of the excised specimen confirmed the diagnosis of PEH. The postoperative course was uneventful with complete resolution of symptoms.</p> Conclusions <p>This case highlights the importance of including PEH in the differential diagnosis of suspicious penile lesions, particularly in elderly patients. Histopathological confirmation through biopsy is crucial to avoid unnecessary radical surgeries, such as partial or total penectomy. Early recognition and appropriate management can preserve function while ensuring optimal patient outcomes.</p>